- Email: [email protected]
General surgery resident experience with anorectal surgery
The American Journal of Surgery xxx (xxxx) xxx
Contents lists available at ScienceDirect
The American Journal of Surgery journal homepage: www.americanjournalofsurgery.com
General surgery resident experience with anorectal surgery Asya Ofshteyn, Morgan Terry, Katherine Bingmer, Sharon L. Stein, Emily Steinhagen* Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospital, Cleveland Medical Center, Cleveland, OH, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 29 April 2019 Received in revised form 7 August 2019 Accepted 8 August 2019
Background: Previous studies have suggested that general surgery residents graduate with suboptimal anorectal experience. However, competence in anorectal procedures is an important part of general surgery training. Methods: ACGME general surgery resident case logs from 1999 to 2017 were reviewed. Mean number of anorectal procedures were evaluated, comparing Period 1 (1999e2008) and Period 2 (2009e2017). Results: Between 1999 and 2017, the mean number of all anorectal procedures performed by each general surgery resident has increased from 25.9 to 32.4 (by 25%). Between Period 1 and 2, mean numbers of total anorectal procedures, abscess drainage, fistula repair, hemorrhoidectomy, prolapse repair, other anorectal procedures all increased (p 0.01). Mean numbers of sphincterotomy/sphincteroplasty and other procedures for fecal incontinence significantly decreased (p 0.01). Conclusions: General surgery residents have gained more experience in some anorectal procedures over time. The required number of procedures to establish competence is not well defined and should be formally evaluated. © 2019 Published by Elsevier Inc.
Keywords: Anorectal disease Resident competency Case numbers General surgery resident training Colorectal surgery ACGME case logs
Introduction Previous studies have suggested that general surgery residents graduate without adequate preparation for practice.1,2 While much of the literature has centered around major operative procedures,3,4 there is concern that their anorectal experience in particular is suboptimal.5,6 Anorectal complaints are among the more common complaints seen by a practicing general surgeon and may be frequently misdiagnosed.7 General surgeons are expected to competently diagnose and manage anorectal problems, as outlined by the Surgical Council on Resident Education.8 The steady increase in number of colon and rectal residents9 and ambulatory surgery centers,10 which typically function without surgical residents could further threaten resident exposure to anorectal procedures. There is concern that general surgery residents have inadequate knowledge of anorectal disease. In a study of resident evaluation of anorectal complaints, residents correctly diagnosed and offered appropriate treatment plan for only 44% patients.6 Additionally, general surgery residents graduate with a perceived lack of
* Corresponding author. Department of Surgery, 11100 Euclid Avenue, LKS 5047, Cleveland, OH, 44106, USA. E-mail address: [email protected] (E. Steinhagen).
experience with anorectal surgery,5 and although general surgeons are expected to manage common colorectal complaints, case volume remains a concern.9 The current general surgery resident experience with anorectal procedures is not described. The aim of this study is to quantify the number and type of anorectal procedures performed by general surgery residents over past eighteen years and understand trends. We hypothesized that resident anorectal numbers would decrease in the context of increasing numbers of post-graduate trainees and ambulatory surgery centers. Methods Accreditation Council for Graduate Medical Education (ACGME) general surgery resident case logs from 1999 to 2017 were reviewed. Anorectal procedures included hemorrhoidectomy, fistula repair, abscess drainage, sphincterotomy and sphincteroplasty, prolapse repair and other procedures for fecal incontinence, and pilonidal cystectomy. Mean numbers of each procedure and total anorectal procedures combined were compiled. Between 2005 and 2010, there was a change in reporting categories that resulted in gaps in fistula repair, abscess drainage, prolapse repair and other procedures for fecal incontinence procedure datasets. During those years fistula repair and abscess drainage were combined into one
https://doi.org/10.1016/j.amjsurg.2019.08.010 0002-9610/© 2019 Published by Elsevier Inc.
Please cite this article as: Ofshteyn A et al., General surgery resident experience with anorectal surgery, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.08.010
2
A. Ofshteyn et al. / The American Journal of Surgery xxx (xxxx) xxx
category; prolapse repair and other procedures for fecal incontinence were similarly combined. The means of individual procedure numbers were trended over time to evaluate changes in individual and combined procedure numbers.
drainage, fistula repair, hemorrhoidectomy, prolapse repair, other anorectal procedures also all increased in a statistically significant way (p 0.01). Mean numbers of sphincterotomy/sphincteroplasty and other procedures for fecal incontinence significantly decreased (p 0.01).
Statistical analysis Trends by case type To evaluate trends, the data was divided into two equal time periods. Period 1 was defined as 2000e2008, and Period 2 was 2009e2017; each year represents the academic year that ends in that numerical calendar year. Individual and combined procedure numbers were compared using the Student's t-test. Pilonidal cyst procedures were excluded from this analysis, as this is not technically an anorectal procedure and because the category was eliminated at the start of Period 2. Results Typical graduating resident experience At the time of graduation, during the study period the typical general surgery resident logged nine hemorrhoidectomies, seven abscess drainage cases, two sphincterotomy or sphincteroplasties, one prolapse repair, and eight unspecified other anorectal procedures (Table 2). The maximum number of any individual procedure done by a graduating resident did not exceed 10.5 cases per year on average, while the maximum combined number of all procedures did not exceed 32.4 cases per year on average. The lowest number of average cases per year in any group was 0.1 in the fecal incontinence procedure category, followed by 0.7 in the fistula repair category (Table 2). Differences between time periods 1 and 2 Between Period 1 and 2, the increase total anorectal procedures was statistically significant (Table 2). Mean numbers of abscess
Between 1999 and 2017, the mean number of all anorectal procedures performed by each general surgery resident has increased from 25.9 to 32.4, representing a 25% increase in anorectal case volume (Table 1). The positive trend starts in approximately 2009 and continues through the end of the study period (Figs. 1 and 2). A similar trend is seen in hemorrhoidectomy (7.6e9.7, 28%), abscess drainage (5.9e8.1, 37%), and other procedures (4.4e10.5, 139%). Prolapse procedures (0.8e1.1, 27%) and fistula repair (0.8e1.3, 63% without initial outlier) appear to have increased but the trend is less linear. Sphincterotomy/sphincteroplasty (2.5e1.5, 44%) and fecal incontinence procedures (0.7e0.1, 86%) are decreasing. Discussion This study demonstrates an increase in anorectal surgery experience for general surgery residents since 1999. This finding is contrary to our hypothesis that the rise in colon and rectal surgery residents and increases in ambulatory surgery centers would diminish general surgery resident experience.9,10 However, the typical resident still graduates with far fewer anorectal procedures compared to other surgeries in the scope of a typical practice for general surgeons. Multiple studies have raised concern that general surgery trainees are not adequately able to diagnose and manage anorectal complaints.6,11 A study of general surgery residents' proficiency regarding colorectal diagnoses demonstrated residents’ difficulty in identifying anal fissures (missed 38% of the time) and thrombosed external hemorrhoids (missed 45% of the time).6 This issue is not
Table 1 Anorectal procedure numbers by year. Year
All n
Abscess Fistula Hemorrhoidectomy Prolapse drainage n(%) repair n(%) n(%) repair n(%)
Other procedure for fecal incontinence n(%)
Sphincterotomy/ sphincteroplasty n(%)
Pilonidal cyst procedure n(%)
Other anorectal procedure n(%)
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Overall meanc 2000 e2017
26.7 25.6 26.4 26.6 26.7 26.1 26.4 25.9 26.4 27.9 25 25.9 27.5 28.7 29.6 29.5 30.7 32.4 27.4
5.9(22) 5.4(21.0) 5.4(20.5) 5.1(19.5) 4.9(18.6) 5.9(22.6)1 6.1(23.2) 6.0(23.3) 6.5(24.6) 6.7(24.1) 5.9(23.7) 6.1(23.6) 6.4(23.4) 6.9(24) 7.2(24.3) 7.2(24.4) 7.8(25.5) 8.1(25.1) 6.3
0.7(2.6) 0.7(2.7) 0.6(2.3) 0.5(1.9) 0.4(1.5)
2.5(9.3) 2.3(9.0) 2.3(8.7) 2.1(8) 2.0(7.6) 1.9(7.3) 1.8(6.8) 1.7(6.6) 1.8(6.8) 1.8(6.5) 1.9(7.6) 1.8(6.9) 1.9(6.9) 1.9(6.6) 1.7(5.7) 1.7(5.8) 1.6(5.2) 1.5(4.6) 1.9
3.5(13.1) 3.4(13.3) 3.4(12.9) 3.6(13.8) 3.6(13.7) 3.4(13) 3.4(12.9) 3.4(13.2) 3.4(12.9) 3.7(13.3)b e e e e e e e e 3.5
4.4(16.4) 4.9(19.1) 5.6(21.3) 6(23) 6.1(23.2) 6.6(25.3) 6.7(25.2) 6.8(26.4) 6.8(25.8) 7.3(26.3) 6.7(26.9) 7.3(28.2) 7.7(28.1) 8.4(29.3) 8.9(30.1) 8.9(30.2) 9.5(31) 10.5(32.5) 7.2
1.4(5.2) 0.8(3.1) 0.7(2.7) 0.9(3.4) 1(3.8)
1.2(4.8) 1.2(4.6) 1.2(4.4) 1.3(4.5) 1.3(4.4) 1.3(4.4) 1.3(4.2) 1.3(4) 1.1
7.6(28.4) 7.3(28.5) 7.5(28.5) 7.2(27.6) 7.5(28.5) 7.1(27.2) 7.2(27.4) 6.8(26.4) 6.8(25.8) 7.1(25.5) 7.9(31.7) 8.3(32) 8.9(32.5) 8.8(30.7) 9.1(30.7) 9.1(30.8) 9.2(30.1) 9.7(30) 8.0
0.8(3) 0.9(3.5) 0.8(3) 0.7(2.7) 0.8(3) 1.2(4.6)a 1.1(4.2) 1.1(4.3) 1.1(4.2) 1.2(4.3) 1.0(4) 1.0(3.9) 1.1(4) 1.2(4.2) 1.2(4.1) 1.1(3.7) 1.1(3.6) 1.1(3.4) 1.0
0.3(1.2) 0.2(0.8) 0.2(0.7) 0.2(0.7) 0.2(0.7) 0.2(0.7) 0.1(0.3) 0.1(0.3) 0.3
a Between 2005 and 2009, abscess drainage and fistula repair as well as prolapse repair and other procedures for fecal incontinence were listed as a combined categories respectively. b Pilonidal cyst procedure category was eliminated after 2009. c Abscess drainage, fistula repair, prolapse repair and other procedures for fecal incontinence overall means exclude 2005e2009.
Please cite this article as: Ofshteyn A et al., General surgery resident experience with anorectal surgery, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.08.010
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Table 2 Procedure data compared between two consecutive time periods of recorded general surgery resident case logs. Procedure
Abscess drainage Fistula repair Hemorrhoidectomy Sphincterotomy/sphincteroplasty Prolapse repair Other procedure for fecal incontinence Other anorectal procedure All anorectal procedures
2000e2008
2009e2017
p value
Mean ± Standard deviation
Maximum
Minimum
Mean ± Standard deviation
Maximum
Minimum
5.34 ± 0.38 0.96 ± 0.27 7.22 ± 0.29 2.04 ± 0.27 0.80 ± 0.07 0.58 ± 0.13 5.99 ± 0.87 26.3 ± 0.38
5.9 1.4 7.6 2.5 0.9 0.7 6.8 26.7
4.9 0.7 6.8 1.7 0.7 0.4 4.4 25.6
6.95 ± 0.38 1.26 ± 0.27 8.68 ± 0.29 1.76 ± 0.27 1.10 ± 0.07 0.19 ± 0.13 8.36 ± 0.87 28.6 ± 2.30
8.1 1.3 9.7 1.9 1.2 0.3 10.5 32.4
5.9 1.2 7.1 1.5 1.0 0.1 6.7 25.0
specific to US training: in the UK, fistulas were significantly more likely to be identified and treated appropriately by more experienced surgeons than trainees at the time of perianal abscess drainage.11 While our study and others specifically examine operative experience, many anorectal issues are addressed in the ambulatory setting. Others have shown that general surgery residency provides suboptimal experience in this area as well.12 Despite these potential training deficits, there are a variety of situations in which surgeons without colorectal specialty training may be expected to manage anorectal complaints. In some centers, acute care or general surgery services may see the majority of acute abscesses, hemorrhoidal issues, and other complaints that present to the emergency department; in some areas, colon and rectal specialists are not available and general surgeons manage all anorectal issues. Therefore, adequate training in diagnosis and management of anorectal problems is an important component of general surgery residency. Compared to other surgical pathology that is typically part of a general surgeon's practice such as hernias, biliary stones, breast pathology, and intraabdominal operations, the number of anorectal procedures required for graduation is much lower. The comparative lack of experience potentially translates into a knowledge and skill deficit for general surgeons. This is demonstrated in a studies that evaluated surgeon's ability to identify anorectal pathology demonstrating that generalists do not have the same diagnostic accuracy for anorectal complaints as specialists despite the frequency of anorectal issues.13,14 Nevertheless, 20% of general surgery residents do not complete fellowships; presumably as practicing general surgeons they are faced with common complaints such as hemorrhoids, fissures, and fistulas in their routine practice.15 For patients, a lack of experienced providers may translate into undertreatment or incorrect treatment for curable and common issues. On a systems level, this translates to increased visits, evaluations, and cost while symptoms are incompletely addressed. Education aimed at increasing comfort and competence with anorectal complaints has the potential to impact a large number of patients. There a large difference in required case numbers between general surgery and colon and rectal residents.9 While general surgery residents are only required to do 20 anorectal cases, colon and rectal residents must log at least 60. Additionally, unlike general surgery residents, colon and rectal residents have defined minimums for specific anorectal case categories. This suggests that experts believe that the required number of anorectal procedures to achieve competence should be higher than it currently is in general surgery residency. It could be suggested that anorectal complaints should be managed by colorectal surgeons alone. This is impractical in many settings, especially in rural and community hospitals were access to specialty care is limited.16 Alternatively, an increase in the required case numbers or an alternative mode of educating general surgery residents might be feasible. This
<0.001 0.01 <0.001 0.01 <0.001 <0.001 <0.001 0.01
provides an opportunity for educational improvement in the area of anorectal disease. Dedicated outpatient surgery rotations, simulations, or even lectures could improve the competence and confidence of the general surgery residency graduates. The reasons behind the overall increase in anorectal surgery cases is not known. One possibility is the overall increase in the number of colon and rectal surgeons who are graduating from a growing number of colon and rectal residencies; when colorectal surgeons join the faculty of a residency program, there is a dramatic increase in the number of anorectal cases for residents.5 The decrease in the sphincterotomy/sphincteroplasty and fecal incontinence categories may be explained by increase in sacral nerve stimulator (SNS) implantation, a highly effective modality for treatment of fecal incontinence that is not captured in current anorectal case log categories.17,18 While case logs provide some insight into the operative experience, there are different degrees of case complexity, levels of resident participation in a procedure, and competence in performing the procedure.19 The coding schema for logging cases does not enable residents to designate complexity; a simple abscess drainage with seton drain placement is logged identically to the operative management of complex perianal Crohn's with abscess.19 A higher complexity case may be predominantly completed by the attending with minimal resident participation.20 It is therefore possible that certain institutions may provide a resident with high anorectal numbers without sufficient hands-on experience. The question of standardizing assessment of anorectal procedure competence remains unaddressed in current general surgery training. This study is limited to the recorded numbers in the ACGME case logs. It is possible that residents do not consistently or accurately log their cases, however this is the only available dataset where these numbers are systematically recorded. It is also possible that there is significant anorectal experience at the bedside, in clinic, or the emergency room that does not get captured within the operative case logs. While the average number of recorded individual and overall procedures was small, this data includes all available years. Additionally, this data includes all general surgery residents in the US. Lastly, the anorectal case categories are poorly defined, and billing codes do not reflect neither actual variety of procedures done nor case complexity.
Conclusions General surgery residents have gained more experience in some anorectal procedures over time. This occurred despite the rise in colon and rectal residents and increase in procedures performed in ambulatory settings. The required number of procedures to establish competence is not well defined and should be formally evaluated.
Please cite this article as: Ofshteyn A et al., General surgery resident experience with anorectal surgery, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.08.010
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Fig. 1. Average anorectal case volume per general surgery resident over time separated by case.
Please cite this article as: Ofshteyn A et al., General surgery resident experience with anorectal surgery, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.08.010
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Fig. 2. Average anorectal case volume per general surgery resident over time combined in one graph.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
9.
10.
Acknowledgements 11.
We acknowledge the support of the University Hospitals Cleveland Medical Center Surgery Department and the University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES).
12.
13.
References 14. 1. Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship. Ann Surg. 2013;258(3):440e449. https:// doi.org/10.1097/SLA.0b013e3182a191ca. 2. Bell RH, Biester TW, Tabuenca A, et al. Operative experience of residents in US general surgery programs. Ann Surg. 2009;249(5):719e724. https://doi.org/ 10.1097/SLA.0b013e3181a38e59. 3. Fonseca AL, Reddy V, Longo WE, Gusberg RJ. Graduating general surgery resident operative confidence: perspective from a national survey. J Surg Res. 2014;190(2):419e428. https://doi.org/10.1016/j.jss.2014.05.014. 4. Bell RH, Biester TW, Tabuenca A, et al. Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg. 2009;249(5):719e724. https://doi.org/10.1097/SLA.0b013e3181a38e59. 5. Hyman NH, Hebert JC. Do general surgery residency programs adequately train surgeons to perform anorectal surgery? Dis Colon Rectum. 1993;36(8): 734e735. https://doi.org/10.1007/BF02048361. 6. Miller S, Sohn V, Causey MW, Martin M, Brown T, Steele S. That's why it's a 5year program: resident acquisition of anorectal disease management competence. J Surg Res. 2012;173(2):187e192. https://doi.org/10.1016/ j.jss.2011.05.048. 7. Idrees JJ, Clapp M, Brady JT, Stein SL, Reynolds HL, Steinhagen E. Evaluating the accuracy of "hemorrhoids": comparison among specialties and symptoms. Dis Colon Rectum. 2019 Jul;62(7):867e871. https://doi.org/10.1097/ DCR.0000000000001315. 8. Surgical Council on Resident Education. General surgery residency curriculum
15.
16.
17.
18.
19.
20.
outline: patient care and medical knowledge. http://www.surgicalcore.org/. Accessed March 10, 2019. Shanker B-A, Soliman M, Williamson P, Ferrara A. Laparoscopic colorectal training gap in colorectal and surgical residents. JSLS J Soc Laparoendosc Surg. 2016;20(3). https://doi.org/10.4293/JSLS.2016.00024. Health Industry Distributors Association (HIDA). Ambulatory Surgery Center Market Report; 2018, 2018 https://www.researchandmarkets.com/research/ 644v8f/2018_ambulatory?w¼4. Accessed March 10, 2019. Malik A, Hall D, Devaney R, Sylvester H, Yalamarthi S. The impact of specialist experience in the surgical management of perianal abscesses. Int J Surg. 2011;9(6):475e477. https://doi.org/10.1016/J.IJSU.2011.06.002. Jones K, Lebron RA, Mangram A, Dunn E. Practice management education during surgical residency. Am J Surg. 2008;196(6):878e881. https://doi.org/ 10.1016/j.amjsurg.2008.08.008. discussion 881-2. Goldstein ET. Outcomes of anorectal disease in a health maintenance organization setting. Dis Colon Rectum. 1996;39(11):1193e1198. https://doi.org/ 10.1007/BF02055107. Grucela A, Salinas H, Khaitov S, Steinhagen RM, Gorfine SR, Chessin DB. Prospective analysis of clinician accuracy in the diagnosis of benign anal pathology: comparison across specialties and years of experience. Dis Colon Rectum. 2010;53(1):47e52. https://doi.org/10.1007/DCR.0b013e3181bbfc89. Klingensmith ME, Cogbill TH, Luchette F, et al. Factors influencing the decision of surgery residency graduates to pursue general surgery practice versus fellowship. Ann Surg. 2015;262(3):449e455. https://doi.org/10.1097/ SLA.0000000000001435. discussion 454-5. Aboagye JK, Kaiser HE, Hayanga AJ. Rural-urban differences in access to specialist providers of colorectal cancer care in the United States. JAMA Surg. 2014;149(6):537. https://doi.org/10.1001/jamasurg.2013.5062. Meyer I, Richter HE. Evidence-based update on treatments of fecal incontinence in women. Obstet Gynecol Clin N Am. 2016;43(1):93e119. https:// doi.org/10.1016/j.ogc.2015.10.005. Wexner SD, Coller JA, Devroede G, et al. Sacral Nerve Stimulation for Fecal Incontinence Results of a 120-Patient Prospective Multicenter Study. 2010. https:// doi.org/10.1097/SLA.0b013e3181cf8ed0. Hiller DJ, Chadi SA, Rosen L, Wexner SD. Consequences of increasing complexity in anorectal surgery performed at an academic center. Dis Colon Rectum. 2019;62(3):343e347. https://doi.org/10.1097/DCR.000000000 0001204. Williams RG, George BC, Bohnen JD, et al. Is the operative autonomy granted to a resident consistent with operative performance quality. Surgery. 2018;164(3):566e570. https://doi.org/10.1016/J.SURG.2018.04.034.
Please cite this article as: Ofshteyn A et al., General surgery resident experience with anorectal surgery, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.08.010
Contents lists available at ScienceDirect
The American Journal of Surgery journal homepage: www.americanjournalofsurgery.com
General surgery resident experience with anorectal surgery Asya Ofshteyn, Morgan Terry, Katherine Bingmer, Sharon L. Stein, Emily Steinhagen* Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospital, Cleveland Medical Center, Cleveland, OH, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 29 April 2019 Received in revised form 7 August 2019 Accepted 8 August 2019
Background: Previous studies have suggested that general surgery residents graduate with suboptimal anorectal experience. However, competence in anorectal procedures is an important part of general surgery training. Methods: ACGME general surgery resident case logs from 1999 to 2017 were reviewed. Mean number of anorectal procedures were evaluated, comparing Period 1 (1999e2008) and Period 2 (2009e2017). Results: Between 1999 and 2017, the mean number of all anorectal procedures performed by each general surgery resident has increased from 25.9 to 32.4 (by 25%). Between Period 1 and 2, mean numbers of total anorectal procedures, abscess drainage, fistula repair, hemorrhoidectomy, prolapse repair, other anorectal procedures all increased (p 0.01). Mean numbers of sphincterotomy/sphincteroplasty and other procedures for fecal incontinence significantly decreased (p 0.01). Conclusions: General surgery residents have gained more experience in some anorectal procedures over time. The required number of procedures to establish competence is not well defined and should be formally evaluated. © 2019 Published by Elsevier Inc.
Keywords: Anorectal disease Resident competency Case numbers General surgery resident training Colorectal surgery ACGME case logs
Introduction Previous studies have suggested that general surgery residents graduate without adequate preparation for practice.1,2 While much of the literature has centered around major operative procedures,3,4 there is concern that their anorectal experience in particular is suboptimal.5,6 Anorectal complaints are among the more common complaints seen by a practicing general surgeon and may be frequently misdiagnosed.7 General surgeons are expected to competently diagnose and manage anorectal problems, as outlined by the Surgical Council on Resident Education.8 The steady increase in number of colon and rectal residents9 and ambulatory surgery centers,10 which typically function without surgical residents could further threaten resident exposure to anorectal procedures. There is concern that general surgery residents have inadequate knowledge of anorectal disease. In a study of resident evaluation of anorectal complaints, residents correctly diagnosed and offered appropriate treatment plan for only 44% patients.6 Additionally, general surgery residents graduate with a perceived lack of
* Corresponding author. Department of Surgery, 11100 Euclid Avenue, LKS 5047, Cleveland, OH, 44106, USA. E-mail address: [email protected] (E. Steinhagen).
experience with anorectal surgery,5 and although general surgeons are expected to manage common colorectal complaints, case volume remains a concern.9 The current general surgery resident experience with anorectal procedures is not described. The aim of this study is to quantify the number and type of anorectal procedures performed by general surgery residents over past eighteen years and understand trends. We hypothesized that resident anorectal numbers would decrease in the context of increasing numbers of post-graduate trainees and ambulatory surgery centers. Methods Accreditation Council for Graduate Medical Education (ACGME) general surgery resident case logs from 1999 to 2017 were reviewed. Anorectal procedures included hemorrhoidectomy, fistula repair, abscess drainage, sphincterotomy and sphincteroplasty, prolapse repair and other procedures for fecal incontinence, and pilonidal cystectomy. Mean numbers of each procedure and total anorectal procedures combined were compiled. Between 2005 and 2010, there was a change in reporting categories that resulted in gaps in fistula repair, abscess drainage, prolapse repair and other procedures for fecal incontinence procedure datasets. During those years fistula repair and abscess drainage were combined into one
https://doi.org/10.1016/j.amjsurg.2019.08.010 0002-9610/© 2019 Published by Elsevier Inc.
Please cite this article as: Ofshteyn A et al., General surgery resident experience with anorectal surgery, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.08.010
2
A. Ofshteyn et al. / The American Journal of Surgery xxx (xxxx) xxx
category; prolapse repair and other procedures for fecal incontinence were similarly combined. The means of individual procedure numbers were trended over time to evaluate changes in individual and combined procedure numbers.
drainage, fistula repair, hemorrhoidectomy, prolapse repair, other anorectal procedures also all increased in a statistically significant way (p 0.01). Mean numbers of sphincterotomy/sphincteroplasty and other procedures for fecal incontinence significantly decreased (p 0.01).
Statistical analysis Trends by case type To evaluate trends, the data was divided into two equal time periods. Period 1 was defined as 2000e2008, and Period 2 was 2009e2017; each year represents the academic year that ends in that numerical calendar year. Individual and combined procedure numbers were compared using the Student's t-test. Pilonidal cyst procedures were excluded from this analysis, as this is not technically an anorectal procedure and because the category was eliminated at the start of Period 2. Results Typical graduating resident experience At the time of graduation, during the study period the typical general surgery resident logged nine hemorrhoidectomies, seven abscess drainage cases, two sphincterotomy or sphincteroplasties, one prolapse repair, and eight unspecified other anorectal procedures (Table 2). The maximum number of any individual procedure done by a graduating resident did not exceed 10.5 cases per year on average, while the maximum combined number of all procedures did not exceed 32.4 cases per year on average. The lowest number of average cases per year in any group was 0.1 in the fecal incontinence procedure category, followed by 0.7 in the fistula repair category (Table 2). Differences between time periods 1 and 2 Between Period 1 and 2, the increase total anorectal procedures was statistically significant (Table 2). Mean numbers of abscess
Between 1999 and 2017, the mean number of all anorectal procedures performed by each general surgery resident has increased from 25.9 to 32.4, representing a 25% increase in anorectal case volume (Table 1). The positive trend starts in approximately 2009 and continues through the end of the study period (Figs. 1 and 2). A similar trend is seen in hemorrhoidectomy (7.6e9.7, 28%), abscess drainage (5.9e8.1, 37%), and other procedures (4.4e10.5, 139%). Prolapse procedures (0.8e1.1, 27%) and fistula repair (0.8e1.3, 63% without initial outlier) appear to have increased but the trend is less linear. Sphincterotomy/sphincteroplasty (2.5e1.5, 44%) and fecal incontinence procedures (0.7e0.1, 86%) are decreasing. Discussion This study demonstrates an increase in anorectal surgery experience for general surgery residents since 1999. This finding is contrary to our hypothesis that the rise in colon and rectal surgery residents and increases in ambulatory surgery centers would diminish general surgery resident experience.9,10 However, the typical resident still graduates with far fewer anorectal procedures compared to other surgeries in the scope of a typical practice for general surgeons. Multiple studies have raised concern that general surgery trainees are not adequately able to diagnose and manage anorectal complaints.6,11 A study of general surgery residents' proficiency regarding colorectal diagnoses demonstrated residents’ difficulty in identifying anal fissures (missed 38% of the time) and thrombosed external hemorrhoids (missed 45% of the time).6 This issue is not
Table 1 Anorectal procedure numbers by year. Year
All n
Abscess Fistula Hemorrhoidectomy Prolapse drainage n(%) repair n(%) n(%) repair n(%)
Other procedure for fecal incontinence n(%)
Sphincterotomy/ sphincteroplasty n(%)
Pilonidal cyst procedure n(%)
Other anorectal procedure n(%)
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Overall meanc 2000 e2017
26.7 25.6 26.4 26.6 26.7 26.1 26.4 25.9 26.4 27.9 25 25.9 27.5 28.7 29.6 29.5 30.7 32.4 27.4
5.9(22) 5.4(21.0) 5.4(20.5) 5.1(19.5) 4.9(18.6) 5.9(22.6)1 6.1(23.2) 6.0(23.3) 6.5(24.6) 6.7(24.1) 5.9(23.7) 6.1(23.6) 6.4(23.4) 6.9(24) 7.2(24.3) 7.2(24.4) 7.8(25.5) 8.1(25.1) 6.3
0.7(2.6) 0.7(2.7) 0.6(2.3) 0.5(1.9) 0.4(1.5)
2.5(9.3) 2.3(9.0) 2.3(8.7) 2.1(8) 2.0(7.6) 1.9(7.3) 1.8(6.8) 1.7(6.6) 1.8(6.8) 1.8(6.5) 1.9(7.6) 1.8(6.9) 1.9(6.9) 1.9(6.6) 1.7(5.7) 1.7(5.8) 1.6(5.2) 1.5(4.6) 1.9
3.5(13.1) 3.4(13.3) 3.4(12.9) 3.6(13.8) 3.6(13.7) 3.4(13) 3.4(12.9) 3.4(13.2) 3.4(12.9) 3.7(13.3)b e e e e e e e e 3.5
4.4(16.4) 4.9(19.1) 5.6(21.3) 6(23) 6.1(23.2) 6.6(25.3) 6.7(25.2) 6.8(26.4) 6.8(25.8) 7.3(26.3) 6.7(26.9) 7.3(28.2) 7.7(28.1) 8.4(29.3) 8.9(30.1) 8.9(30.2) 9.5(31) 10.5(32.5) 7.2
1.4(5.2) 0.8(3.1) 0.7(2.7) 0.9(3.4) 1(3.8)
1.2(4.8) 1.2(4.6) 1.2(4.4) 1.3(4.5) 1.3(4.4) 1.3(4.4) 1.3(4.2) 1.3(4) 1.1
7.6(28.4) 7.3(28.5) 7.5(28.5) 7.2(27.6) 7.5(28.5) 7.1(27.2) 7.2(27.4) 6.8(26.4) 6.8(25.8) 7.1(25.5) 7.9(31.7) 8.3(32) 8.9(32.5) 8.8(30.7) 9.1(30.7) 9.1(30.8) 9.2(30.1) 9.7(30) 8.0
0.8(3) 0.9(3.5) 0.8(3) 0.7(2.7) 0.8(3) 1.2(4.6)a 1.1(4.2) 1.1(4.3) 1.1(4.2) 1.2(4.3) 1.0(4) 1.0(3.9) 1.1(4) 1.2(4.2) 1.2(4.1) 1.1(3.7) 1.1(3.6) 1.1(3.4) 1.0
0.3(1.2) 0.2(0.8) 0.2(0.7) 0.2(0.7) 0.2(0.7) 0.2(0.7) 0.1(0.3) 0.1(0.3) 0.3
a Between 2005 and 2009, abscess drainage and fistula repair as well as prolapse repair and other procedures for fecal incontinence were listed as a combined categories respectively. b Pilonidal cyst procedure category was eliminated after 2009. c Abscess drainage, fistula repair, prolapse repair and other procedures for fecal incontinence overall means exclude 2005e2009.
Please cite this article as: Ofshteyn A et al., General surgery resident experience with anorectal surgery, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.08.010
A. Ofshteyn et al. / The American Journal of Surgery xxx (xxxx) xxx
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Table 2 Procedure data compared between two consecutive time periods of recorded general surgery resident case logs. Procedure
Abscess drainage Fistula repair Hemorrhoidectomy Sphincterotomy/sphincteroplasty Prolapse repair Other procedure for fecal incontinence Other anorectal procedure All anorectal procedures
2000e2008
2009e2017
p value
Mean ± Standard deviation
Maximum
Minimum
Mean ± Standard deviation
Maximum
Minimum
5.34 ± 0.38 0.96 ± 0.27 7.22 ± 0.29 2.04 ± 0.27 0.80 ± 0.07 0.58 ± 0.13 5.99 ± 0.87 26.3 ± 0.38
5.9 1.4 7.6 2.5 0.9 0.7 6.8 26.7
4.9 0.7 6.8 1.7 0.7 0.4 4.4 25.6
6.95 ± 0.38 1.26 ± 0.27 8.68 ± 0.29 1.76 ± 0.27 1.10 ± 0.07 0.19 ± 0.13 8.36 ± 0.87 28.6 ± 2.30
8.1 1.3 9.7 1.9 1.2 0.3 10.5 32.4
5.9 1.2 7.1 1.5 1.0 0.1 6.7 25.0
specific to US training: in the UK, fistulas were significantly more likely to be identified and treated appropriately by more experienced surgeons than trainees at the time of perianal abscess drainage.11 While our study and others specifically examine operative experience, many anorectal issues are addressed in the ambulatory setting. Others have shown that general surgery residency provides suboptimal experience in this area as well.12 Despite these potential training deficits, there are a variety of situations in which surgeons without colorectal specialty training may be expected to manage anorectal complaints. In some centers, acute care or general surgery services may see the majority of acute abscesses, hemorrhoidal issues, and other complaints that present to the emergency department; in some areas, colon and rectal specialists are not available and general surgeons manage all anorectal issues. Therefore, adequate training in diagnosis and management of anorectal problems is an important component of general surgery residency. Compared to other surgical pathology that is typically part of a general surgeon's practice such as hernias, biliary stones, breast pathology, and intraabdominal operations, the number of anorectal procedures required for graduation is much lower. The comparative lack of experience potentially translates into a knowledge and skill deficit for general surgeons. This is demonstrated in a studies that evaluated surgeon's ability to identify anorectal pathology demonstrating that generalists do not have the same diagnostic accuracy for anorectal complaints as specialists despite the frequency of anorectal issues.13,14 Nevertheless, 20% of general surgery residents do not complete fellowships; presumably as practicing general surgeons they are faced with common complaints such as hemorrhoids, fissures, and fistulas in their routine practice.15 For patients, a lack of experienced providers may translate into undertreatment or incorrect treatment for curable and common issues. On a systems level, this translates to increased visits, evaluations, and cost while symptoms are incompletely addressed. Education aimed at increasing comfort and competence with anorectal complaints has the potential to impact a large number of patients. There a large difference in required case numbers between general surgery and colon and rectal residents.9 While general surgery residents are only required to do 20 anorectal cases, colon and rectal residents must log at least 60. Additionally, unlike general surgery residents, colon and rectal residents have defined minimums for specific anorectal case categories. This suggests that experts believe that the required number of anorectal procedures to achieve competence should be higher than it currently is in general surgery residency. It could be suggested that anorectal complaints should be managed by colorectal surgeons alone. This is impractical in many settings, especially in rural and community hospitals were access to specialty care is limited.16 Alternatively, an increase in the required case numbers or an alternative mode of educating general surgery residents might be feasible. This
<0.001 0.01 <0.001 0.01 <0.001 <0.001 <0.001 0.01
provides an opportunity for educational improvement in the area of anorectal disease. Dedicated outpatient surgery rotations, simulations, or even lectures could improve the competence and confidence of the general surgery residency graduates. The reasons behind the overall increase in anorectal surgery cases is not known. One possibility is the overall increase in the number of colon and rectal surgeons who are graduating from a growing number of colon and rectal residencies; when colorectal surgeons join the faculty of a residency program, there is a dramatic increase in the number of anorectal cases for residents.5 The decrease in the sphincterotomy/sphincteroplasty and fecal incontinence categories may be explained by increase in sacral nerve stimulator (SNS) implantation, a highly effective modality for treatment of fecal incontinence that is not captured in current anorectal case log categories.17,18 While case logs provide some insight into the operative experience, there are different degrees of case complexity, levels of resident participation in a procedure, and competence in performing the procedure.19 The coding schema for logging cases does not enable residents to designate complexity; a simple abscess drainage with seton drain placement is logged identically to the operative management of complex perianal Crohn's with abscess.19 A higher complexity case may be predominantly completed by the attending with minimal resident participation.20 It is therefore possible that certain institutions may provide a resident with high anorectal numbers without sufficient hands-on experience. The question of standardizing assessment of anorectal procedure competence remains unaddressed in current general surgery training. This study is limited to the recorded numbers in the ACGME case logs. It is possible that residents do not consistently or accurately log their cases, however this is the only available dataset where these numbers are systematically recorded. It is also possible that there is significant anorectal experience at the bedside, in clinic, or the emergency room that does not get captured within the operative case logs. While the average number of recorded individual and overall procedures was small, this data includes all available years. Additionally, this data includes all general surgery residents in the US. Lastly, the anorectal case categories are poorly defined, and billing codes do not reflect neither actual variety of procedures done nor case complexity.
Conclusions General surgery residents have gained more experience in some anorectal procedures over time. This occurred despite the rise in colon and rectal residents and increase in procedures performed in ambulatory settings. The required number of procedures to establish competence is not well defined and should be formally evaluated.
Please cite this article as: Ofshteyn A et al., General surgery resident experience with anorectal surgery, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.08.010
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A. Ofshteyn et al. / The American Journal of Surgery xxx (xxxx) xxx
Fig. 1. Average anorectal case volume per general surgery resident over time separated by case.
Please cite this article as: Ofshteyn A et al., General surgery resident experience with anorectal surgery, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.08.010
A. Ofshteyn et al. / The American Journal of Surgery xxx (xxxx) xxx
5
Fig. 2. Average anorectal case volume per general surgery resident over time combined in one graph.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
9.
10.
Acknowledgements 11.
We acknowledge the support of the University Hospitals Cleveland Medical Center Surgery Department and the University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES).
12.
13.
References 14. 1. Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship. Ann Surg. 2013;258(3):440e449. https:// doi.org/10.1097/SLA.0b013e3182a191ca. 2. Bell RH, Biester TW, Tabuenca A, et al. Operative experience of residents in US general surgery programs. Ann Surg. 2009;249(5):719e724. https://doi.org/ 10.1097/SLA.0b013e3181a38e59. 3. Fonseca AL, Reddy V, Longo WE, Gusberg RJ. Graduating general surgery resident operative confidence: perspective from a national survey. J Surg Res. 2014;190(2):419e428. https://doi.org/10.1016/j.jss.2014.05.014. 4. Bell RH, Biester TW, Tabuenca A, et al. Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg. 2009;249(5):719e724. https://doi.org/10.1097/SLA.0b013e3181a38e59. 5. Hyman NH, Hebert JC. Do general surgery residency programs adequately train surgeons to perform anorectal surgery? Dis Colon Rectum. 1993;36(8): 734e735. https://doi.org/10.1007/BF02048361. 6. Miller S, Sohn V, Causey MW, Martin M, Brown T, Steele S. That's why it's a 5year program: resident acquisition of anorectal disease management competence. J Surg Res. 2012;173(2):187e192. https://doi.org/10.1016/ j.jss.2011.05.048. 7. Idrees JJ, Clapp M, Brady JT, Stein SL, Reynolds HL, Steinhagen E. Evaluating the accuracy of "hemorrhoids": comparison among specialties and symptoms. Dis Colon Rectum. 2019 Jul;62(7):867e871. https://doi.org/10.1097/ DCR.0000000000001315. 8. Surgical Council on Resident Education. General surgery residency curriculum
15.
16.
17.
18.
19.
20.
outline: patient care and medical knowledge. http://www.surgicalcore.org/. Accessed March 10, 2019. Shanker B-A, Soliman M, Williamson P, Ferrara A. Laparoscopic colorectal training gap in colorectal and surgical residents. JSLS J Soc Laparoendosc Surg. 2016;20(3). https://doi.org/10.4293/JSLS.2016.00024. Health Industry Distributors Association (HIDA). Ambulatory Surgery Center Market Report; 2018, 2018 https://www.researchandmarkets.com/research/ 644v8f/2018_ambulatory?w¼4. Accessed March 10, 2019. Malik A, Hall D, Devaney R, Sylvester H, Yalamarthi S. The impact of specialist experience in the surgical management of perianal abscesses. Int J Surg. 2011;9(6):475e477. https://doi.org/10.1016/J.IJSU.2011.06.002. Jones K, Lebron RA, Mangram A, Dunn E. Practice management education during surgical residency. Am J Surg. 2008;196(6):878e881. https://doi.org/ 10.1016/j.amjsurg.2008.08.008. discussion 881-2. Goldstein ET. Outcomes of anorectal disease in a health maintenance organization setting. Dis Colon Rectum. 1996;39(11):1193e1198. https://doi.org/ 10.1007/BF02055107. Grucela A, Salinas H, Khaitov S, Steinhagen RM, Gorfine SR, Chessin DB. Prospective analysis of clinician accuracy in the diagnosis of benign anal pathology: comparison across specialties and years of experience. Dis Colon Rectum. 2010;53(1):47e52. https://doi.org/10.1007/DCR.0b013e3181bbfc89. Klingensmith ME, Cogbill TH, Luchette F, et al. Factors influencing the decision of surgery residency graduates to pursue general surgery practice versus fellowship. Ann Surg. 2015;262(3):449e455. https://doi.org/10.1097/ SLA.0000000000001435. discussion 454-5. Aboagye JK, Kaiser HE, Hayanga AJ. Rural-urban differences in access to specialist providers of colorectal cancer care in the United States. JAMA Surg. 2014;149(6):537. https://doi.org/10.1001/jamasurg.2013.5062. Meyer I, Richter HE. Evidence-based update on treatments of fecal incontinence in women. Obstet Gynecol Clin N Am. 2016;43(1):93e119. https:// doi.org/10.1016/j.ogc.2015.10.005. Wexner SD, Coller JA, Devroede G, et al. Sacral Nerve Stimulation for Fecal Incontinence Results of a 120-Patient Prospective Multicenter Study. 2010. https:// doi.org/10.1097/SLA.0b013e3181cf8ed0. Hiller DJ, Chadi SA, Rosen L, Wexner SD. Consequences of increasing complexity in anorectal surgery performed at an academic center. Dis Colon Rectum. 2019;62(3):343e347. https://doi.org/10.1097/DCR.000000000 0001204. Williams RG, George BC, Bohnen JD, et al. Is the operative autonomy granted to a resident consistent with operative performance quality. Surgery. 2018;164(3):566e570. https://doi.org/10.1016/J.SURG.2018.04.034.
Please cite this article as: Ofshteyn A et al., General surgery resident experience with anorectal surgery, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.08.010