- Email: [email protected]
General surgery resident rotations in surgical critical care, trauma, and burns: what is optimal for residency training?
Accepted Manuscript General Surgery Resident Rotations in Surgical Critical Care, Trauma and Burns: What is Optimal for Residency Training? Lena M. Napolitano, M.D., FACS, Thomas W. Biester, M.S., Gregory J. Jurkovich, M.D., FACS, Jo Buyske, M.D., FACS, Mark A. Malangoni, M.D., FACS, Frank R. Lewis, Jr., M.D., FACS PII:
S0002-9610(16)30415-9
DOI:
10.1016/j.amjsurg.2016.07.016
Reference:
AJS 12027
To appear in:
The American Journal of Surgery
Received Date: 21 January 2016 Revised Date:
25 July 2016
Accepted Date: 29 July 2016
Please cite this article as: Napolitano LM, Biester TW, Jurkovich GJ, Buyske J, Malangoni MA, Lewis Jr. FRMembers of the Trauma, Burns and Critical Care Board of the American Board of Surgery, General Surgery Resident Rotations in Surgical Critical Care, Trauma and Burns: What is Optimal for Residency Training?, The American Journal of Surgery (2016), doi: 10.1016/j.amjsurg.2016.07.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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General Surgery Resident Rotations in Surgical Critical Care, Trauma and Burns: What is Optimal for Residency Training?
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Lena M. Napolitano M.D., FACS Thomas W. Biester M.S. Gregory J. Jurkovich M.D., FACS Jo Buyske M.D., FACS Mark A. Malangoni M.D., FACS Frank R. Lewis Jr. M.D., FACS Members of the Trauma, Burns and Critical Care Board of the American Board of Surgery
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For submission to American Journal of Surgery, AWS Edition Original Article; Tables 8; References 25 Short title: Resident Training in Critical Care, Trauma & Burns (43 characters) Keywords: surgical critical care, trauma, burn, general surgery, resident, rotation, duration, general surgery residency training The authors have no conflict of interest. No funding support for this work.
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Members of the Trauma, Burns and Critical Care Board of the American Board of Surgery Roxie M. Albrecht, M.D., FACS Karen J. Brasel, M.D., FACS Eileen M. Bulger, M.D., FACS Martin A. Croce, M.D., FACS David G. Greenhalgh, M.D., FACS Pamela A. Lipsett, M.D., FACS Frederick A. Luchette, M.D., FACS Robert C. Mackersie, M.D., FACS Anne G. Rizzo, M.D., FACS Ronald M. Stewart, M.D., FACS David A. Spain, M.D., FACS
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Corresponding author: Lena M. Napolitano MD, FACS, FCCP, FCCM Professor of Surgery Division Chief, Acute Care Surgery [Trauma, Burns, Critical Care, Emergency Surgery] Director, Trauma and Surgical Critical Care Associate Chair, Department of Surgery 1C421 University Hospital, Box 0033 1500 E. Medical Center Drive Ann Arbor, MI 48109-0033 Phone 734-615-4775 Fax 734-936-9657 Email [email protected] 1
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ABSTRACT Background: There are no specific ACGME General Surgery Residency Program Requirements for rotations in surgical critical care (SCC), trauma and burn. We sought to
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determine the experience of general surgery residents in SCC, trauma and burn rotations.
Methods: Data analysis of surgical rotations of American Board of Surgery (ABS) general surgery resident applicants (n=7299) for the last 8 years (2006-2013, inclusive) was performed
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through electronic applications to the ABS Qualifying Examination (QE). Duration (months) spent in SCC, trauma and burn rotations, and post-graduate year (PGY) level were examined.
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Results: The mean/median total months in SCC, trauma and burn rotations was 10.2/10.0 (SD 3.9 months), representing approximately 16.7% (10 of 60 months) of a general surgery resident’s training. However, there was great variability (range 0-29 months). Mean/median SCC rotation duration was 3.1/3.0 months (SD 2, min-max 0-15), 6.3/6.0 months (SD 3.5, min-max 0-24) for
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trauma and 0.8/1.0 months (SD 1.0, min-max 0-6) for burn. Of the total mean 10.2 months duration, the longest exposure was 2 months as PGY-1, 3.4 months as PGY-2, 1.9 months as PGY-3, 2.2 months as PGY-4 and 1.1 months as PGY-5 . PGY-5 residents spent a mean of 1
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month in SCC, trauma and burn rotations. PGY-4/5 residents spent the majority of this total time in trauma rotations, whereas junior residents (PGY-1-3) in SCC and trauma rotations.
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Conclusion: There is significant variability in total duration of SCC, trauma and burn rotations and PGY level in U.S. general surgery residency programs, which may result in significant variability in the fund of knowledge and clinical experience of the trainee completing general surgery residency training. As acute care surgery programs have begun to integrate emergency general surgery with SCC, trauma and burn rotations, it is an ideal time to determine the optimal curriculum and duration of these important rotations for general surgery residency training.
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General Surgery Resident Rotations in Surgical Critical Care, Trauma and Burns: What is Optimal for Residency Training?
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Lena M. Napolitano M.D., FACS Thomas W. Biester M.S. Gregory J. Jurkovich M.D., FACS Jo Buyske M.D., FACS Mark A. Malangoni M.D., FACS Frank R. Lewis Jr. M.D., FACS Members of the Trauma, Burns and Critical Care Board of the American Board of Surgery
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Original Article; Tables 8; References 25 Short title: Resident Training in Critical Care, Trauma & Burns (43 characters) Keywords: surgical critical care, trauma, burn, general surgery, resident, rotation, duration, general surgery residency training The authors have no conflict of interest. No funding support for this work.
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Members of the Trauma, Burns and Critical Care Board of the American Board of Surgery Roxie M. Albrecht, M.D., FACS Karen J. Brasel, M.D., FACS Eileen M. Bulger, M.D., FACS Martin A. Croce, M.D., FACS David G. Greenhalgh, M.D., FACS Pamela A. Lipsett, M.D., FACS Frederick A. Luchette, M.D., FACS Robert C. Mackersie, M.D., FACS Anne G. Rizzo, M.D., FACS Ronald M. Stewart, M.D., FACS David A. Spain, M.D., FACS
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Corresponding author: Lena M. Napolitano MD, FACS, FCCP, FCCM Professor of Surgery Division Chief, Acute Care Surgery [Trauma, Burns, Critical Care, Emergency Surgery] Director, Trauma and Surgical Critical Care Associate Chair, Department of Surgery 1C421 University Hospital, Box 0033 1500 E. Medical Center Drive Ann Arbor, MI 48109-0033 Phone 734-615-4775 Fax 734-936-9657 Email: [email protected]
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ABSTRACT Background: There are no specific ACGME General Surgery Residency Program Requirements for rotations in surgical critical care (SCC), trauma and burn. We sought to
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determine the experience of general surgery residents in SCC, trauma and burn rotations.
Methods: Data analysis of surgical rotations of American Board of Surgery (ABS) general surgery resident applicants (n=7299) for the last 8 years (2006-2013, inclusive) was performed
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through electronic applications to the ABS Qualifying Examination (QE). Duration (months) spent in SCC, trauma and burn rotations, and post-graduate year (PGY) level were examined.
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Results: The mean/median total months in SCC, trauma and burn rotations was 10.2/10.0 (SD 3.9 months), representing approximately 16.7% (10 of 60 months) of a general surgery resident’s training. However, there was great variability (range 0-29 months). Mean/median SCC rotation duration was 3.1/3.0 months (SD 2, min-max 0-15), 6.3/6.0 months (SD 3.5, min-max 0-24) for
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trauma and 0.8/1.0 months (SD 1.0, min-max 0-6) for burn. Of the total mean 10.2 months duration, the longest exposure was 2 months as PGY-1, 3.4 months as PGY-2, 1.9 months as PGY-3, 2.2 months as PGY-4 and 1.1 months as PGY-5 . PGY-5 residents spent a mean of 1
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month in SCC, trauma and burn rotations. PGY-4/5 residents spent the majority of this total time in trauma rotations, whereas junior residents (PGY-1-3) in SCC and trauma rotations.
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Conclusion: There is significant variability in total duration of SCC, trauma and burn rotations and PGY level in U.S. general surgery residency programs, which may result in significant variability in the fund of knowledge and clinical experience of the trainee completing general surgery residency training. As acute care surgery programs have begun to integrate emergency general surgery with SCC, trauma and burn rotations, it is an ideal time to determine the optimal curriculum and duration of these important rotations for general surgery residency training.
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INTRODUCTION The Trauma, Burns and Critical Care Board of the American Board of Surgery has been concerned that our current resident training paradigm in General Surgery potentially provides
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inadequate experience and clinical rotations in surgical critical care (SCC), trauma and burns which is necessary for optimal care of our surgical patients. 1 2 3 There is also considerable
concern that graduating residents are not adequately prepared for independent surgical practice. 4
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Since the Accreditation Council for Graduate Medical Education (ACGME) mandated a significant reduction in resident work hours, physician manpower in more labor-intense units
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(such as intensive care units) has transitioned to advanced practice providers to provide patient care and procedures. 5 6 7 8 Increased utilization of advanced practice providers may have a negative impact on surgical resident education and experience in surgical critical care. 9 The current ACGME General Surgery Residency Program Requirements 10 are quite vague with
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regard to the optimal time required in SCC, trauma and burn rotations during general surgery residency (Table 1). National efforts to reform general surgery residency education have been ongoing, but a critical analysis of the specific general surgery residency rotation requirements in
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SCC, trauma and burns has not yet been addressed. We sought to determine the experience of general surgery residents in SCC, trauma and
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burns during their general surgery residency training and examined the duration of rotations in these areas and the specific PGY-level when they occurred for general surgery residents.
METHODS
We analyzed de-identified data of the surgical rotations of applicants to the American Board of Surgery (ABS) Qualifying Examination (QE) over an eight (8) year period, from 2006-
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2013, inclusive. General surgery resident rotation data submitted through electronic applications were examined. We determined the number of months spent in SCC, trauma and burn rotations, and at what post-graduate year (PGY) level for general surgery residents using candidate rotation
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lists and analyzed by the ABS psychometrician (TWB).
Data from the ABS electronic applications were self-reported. Residents indicated the beginning/end and location (hospital) of the rotation, and chose a rotation description from a
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drop-down menu included on the ABS QE application form. The instructions on the ABS QE application form are: “You must list chronologically all rotations and activities from the
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beginning of residency, including all time away from training (including time taken for vacation, interviews, medical leave, visa issues, and early departures for fellowships). Each rotation must be listed separately by clinical activity, not grouped together as a yearly total.” There were 3 rotations of interest included on the ABS QE application: (1) SCC (logged
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as ICU-SICU on QE application); (2) Trauma; and (3) Burns. Records were excluded for (1) residents who recorded less than 5 years of rotation experience (e.g., those who received credit for foreign training) or more than five years of clinical activity (e.g., transfers, remedial/repeat
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years), (2) residents who did not accurately complete the rotations section of the QE application and (3) residents who completed their training during this time period but never applied for the
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ABS QE. Records were available for 7299 of 8676 general surgery residents who completed their training over the 8-year period (84.1% of all residents). Statistical Analysis: Descriptive statistics [mean, median, standard deviation (SD)] were used to report the total months of experience in SCC, trauma and burns rotations for general surgery residents as a group, and by specific post-graduate year.
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RESULTS Table 2 reports residents’ total months in all SCC, trauma and burn rotations during general surgery residency. The mean number of months in SCC, trauma and burn rotations for
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general surgery residents was 10.2 months (SD 3.9 months), representing approximately 16.7% (10 of 60 months) of residency training. However, there was wide variability reported, as
reflected by the minimum-maximum range of 0 to 29 months. It should be noted that the mean
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total number of months has been constant over this 8-year period with no downward trend. Table 3 reports residents’ total months in SCC rotations during general surgery
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residency. The mean number of months in SCC rotations was 3.1 months (SD 2 months), with a minimum-maximum range of 0 to 15 months.
Table 4 reports residents’ total months in Burn rotations during general surgery residency. The mean number of months in Burn rotations was 0.8 months (SD 1.0 months), with
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a minimum-maximum range of 0 to 6 months.
Table 5 reports residents’ total months in Trauma rotations during general surgery residency. The mean number of months in Trauma rotations was 6.3 months (SD 3.5 months),
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with a minimum-maximum range of 0 to 24 months. Table 6 provides data regarding general surgery resident rotation in SCC, trauma and
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burn by resident post-graduate year. Of the total mean 10.2 months duration in these rotations by general surgery residents, the longest mean exposure was 2 months as PGY-1, 3.4 months as PGY-2, 1.9 months as PGY-3, 2.2 months as PGY-4 and 1.1 months as PGY-5. PGY-5 residents spent a mean of 1 month in SCC, trauma and burn rotations. PGY-4/5 residents spent the majority of this total time in trauma rotations, whereas junior residents (PGY-1-3) spent the majority of this total time in SCC and trauma rotations.
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DISCUSSION In this study, we have identified that there is significant variability in the duration of rotations in SCC, trauma and burn during general surgery residency. It is unclear whether the
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current rotations provide competency-based education to meet the SCORE Curriculum General Surgery requirements in these three areas (SCC, trauma and burn). Almost all of the SCORE modules in these three areas are delineated as “core” patient care topics. 11
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Since one of the goals of general surgery residency training is to prepare for initial board certification in general surgery, then optimal duration in these rotations should prepare residents
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to meet the ABS requirements, including the ABSITE, Qualifying Examination (QE) and Certifying Examination (CE). The ABS states that residency training in general surgery requires experience in all of the following content areas, including SCC, trauma and burn 12: Alimentary Tract (including Bariatric Surgery); Abdomen and its Contents; Breast, Skin and Soft Tissue;
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Endocrine System; Solid Organ Transplantation; Pediatric Surgery; Surgical Critical Care; Surgical Oncology (including Head and Neck Surgery); Trauma/Burns and Emergency Surgery and Vascular Surgery.
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In the ABSITE, 5% of the questions are related to the category of SCC and 6% of questions are in the category of Trauma (Table 7). 13 Therefore a total of 11% of questions in
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the ABSITE are in the categories of SCC, trauma and burn knowledge. The number of questions related to SCC and Trauma on the ABSITE has significantly decreased compared to prior years. It has been documented that ABSITE scores are a useful predictor of QE scores and outcomes, but do not predict passing the CE. 14 The ABS' minimum requirements for the QE application are 750 procedures in five years and 150 in the chief senior year, with an overall balanced distribution of cases. Residents may
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count up to 50 cases as teaching assistant toward the 750 total; however these cases may not be counted toward the 150 chief year cases. Applicants who finish residency in 2009-2010 and thereafter must also list at least 25
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cases in surgical critical care, with a minimum of one in each of the area’s 7 categories. 15 The Critical Care Index Cases (CCIC) log was developed to provide documentation of resident
management of a broad scope of critical care patients as follows: Each resident must develop a
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log of at least 25 critical care patients who represent the broad scope of critical care index
the following 7 categories:
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management. Each of the patients listed in the log should include the management of at least 2 of
•8410 - Ventilator Management (>24 hours on a ventilator)
•8420 - Hemorrhage (a non-trauma patient requiring more than 3 units of blood/products and monitoring in ICU settings)
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•8430 - Hemodynamic Instability requiring vasoactive/inotropic agents •8440 - Organ Failure (i.e., renal, hepatic, endocrine, CNS, cardiac failure) •8450 - Dysrhythmias (requiring drug management) •8460 - Invasive Monitors (Pulmonary artery catheter, central venous line, arterial line,
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Intracranial Pressure monitor/continuous EEG/LICOX/Jugular Bulb oximetry)
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•8470 – Nutritional support (Parenteral/Enteral Nutrition Cases must also be reported for operative and nonoperative trauma. Prior to 2003, the
RRC requirement was 16 trauma operative cases. 16 Since 2003-2004, the RRC has required general surgery residency graduates must have a minimum of 30 trauma cases for graduation. Of the 30 required cases, 10 will be the minimum number of operative trauma cases; 20 will be the minimum number of non-operative cases which are recorded using the CPT code 99199.
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In the ABS QE, 10% of the questions are related to the category of SCC, and 8% of questions are in the category of Trauma (Table 8). Therefore a total of 18% of the questions in the ABS QE are in the categories of SCC, trauma and burn knowledge.
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In order to provide optimal patient care, and to meet these ABS requirements for
certification, what is the optimal duration of rotations in SCC, trauma and burns for general surgery residents? How can we ensure that the SCORE standardized curriculum content in these
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areas is completed during these rotations for competency-based resident advancement? Little data are available in the published peer-reviewed literature regarding this topic of optimal
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general surgery residency training and optimal rotation duration in SCC, trauma and burn surgery.
A single-institution study distributed anonymous surveys to categorical general surgery residents in their large, university-based residency program to measure the residents’ experience
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in surgical critical care. 17 At the time of the survey, 52 respondents had completed 9.3±4.5 weeks of SCC rotations. Despite no rotations beyond PGY3, senior residents (PGYs 4/5) reported significantly greater SCC training time (13.1 vs. 7.8 weeks) and comfort managing SCC
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diseases and procedures than juniors (PGY 3). The mean education satisfaction score was 3.9 +/- 0.9 (5 = extremely satisfied). Residents anticipated performing minimal SCC management of
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their own patients, but most felt that SCC-trained surgeons should manage critically-ill surgery patients. Senior residents reported greater SCC fellowship interest (19% versus 0%). The addition of acute care surgery increased interest in 30% of respondents. The authors concluded that senior residents reported greater comfort with SCC management despite the lack of senior SCC rotations, while dedicated SCC training time for junior residents appears to be declining.
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Regarding general surgery residents’ rotation in trauma surgery, the resident experience has substantially changed related to increasing nonoperative management of trauma patients, especially for abdominal solid organ injuries. Data from a large multicenter (82 trauma centers
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representing over 247,000 trauma admissions) study documented that surgical resident
experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of major operative procedures. They reported that assuming 1 night of 4
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on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, and the resident will care for an
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average of 500 blunt trauma patients before performing a splenectomy or liver repair. 18 Another report from two ACS-verified trauma centers documented that 85% (370 of 434) of trauma patients were managed without an index trauma surgical procedure according to RRC guidelines. Only 14.7% (64 of 434) of patients underwent operative intervention that qualified as
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an index trauma surgical case identified by the RRC, with an average of 6.4 trauma cases per chief resident. The spleen and small bowel were the two most commonly injured organs found at laparotomy. Nonoperative intervention of many patients with solid abdominal organ injuries did
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not meet the operation requirements expected by the RRC. 19 A recent study analyzed the reported volume of operative trauma to examine nationwide
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trends over the last two decades. The ACGME database of operative logs was queried from academic year 1989-1990 to 2009-2010 to identify shifts in trauma operative experience and examined in four 5-year blocks. Significant declines in ACGME-designated trauma cases was identified in the four 5-year blocks (75.5 vs. 54.5 vs. 39.3 vs. 39.4 cases, p<0.001). In comparison, overall general surgery caseload increased from the first to second block, but decreased in the last two most recent blocks. This study confirmed that recent general surgery
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trainees performed fewer trauma operations than previous trainees [31 abdominal trauma operations (5 spleen, 4 liver) in first block compared to 17 abdominal trauma operations (3 20
Additional studies confirm these findings of reduced
trauma operative experience for general surgery residents.
21 22
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spleen, 2 liver) in most recent block].
The data from this current study document significant variability both in duration and specific PGY-level for SCC, trauma and burn rotations. Since SCC, trauma and burn are
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essential content areas of general surgery, this significant variability is not ideal as it may result in significant differences in both fund of knowledge and clinical experience in the care of these
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specific patients for senior surgery trainees completing general surgery residency. Furthermore, it may impact on ABS certification success. Future research should investigate whether general surgery residents who have longer duration in SCC, trauma and burn rotations perform better on the ABSITE, QE and CE examinations, and determine whether this is related to improved
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performance in the specific content areas relevant to these surgical rotations. There are some limitations to this study. Some residents may designate SCC, trauma and/or burn rotations simply as “General Surgery” and it is possible that some of their specific
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experience in these three areas may be underestimated. Furthermore, coding errors in the resident entries regarding their residency rotations were possible.
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In addition to the important finding of wide variability both in duration and specific
PGY-level for SCC, trauma and burn rotations, we recognize that many programs have now established an acute care surgery model 23 24 25which integrates emergency general surgery into SCC, trauma and/or burn rotations. Given the findings of this study and the reorganization into acute care surgery for many institutions, the time is ideal to standardize curriculum content and determine optimal duration of these important rotations for general surgery residency training for
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competency-based advancement in SCC, trauma and burn. The Trauma, Burns and Critical Care Board of the ABS is currently in discussion regarding optimal competency-based general surgery
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residency training in the areas of SCC, trauma and burns.
CONCLUSION:
There is significant variability in total duration of SCC, trauma and burn rotations and PGY level
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in U.S. general surgery residency programs, which may result in significant variability in the fund of knowledge and clinical experience of the trainee completing general surgery residency
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training. As acute care surgery programs have begun to integrate emergency general surgery with SCC, trauma and burn rotations, it is an ideal time to determine the optimal curriculum and
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duration of these important rotations for general surgery residency training.
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Table 1. ACGME Program Requirements for General Surgery Residency Training “IV.A.6.a).(2) The 60-month clinical program should be organized as follows: (Core)
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IV.A.6.a).(2).(a) At least 54 months of the 60-month program must be spent on clinical assignments in surgery, with documented experience in emergency care and surgical critical care in order to enable residents to manage patients with severe and complex illnesses and with major injuries. (Core)
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IV.A.6.a).(2).(b) 42 months of these 54 months must be spent on clinical assignments in the essential content areas of surgery. (Core) IV.A.6.a).(2).(b).(i) The essential content areas are: the abdomen and its contents; the alimentary tract; skin, soft tissues, and breast; endocrine surgery; head and neck surgery; pediatric surgery; surgical critical care; surgical oncology; trauma and nonoperative trauma (burn experience that includes patient management may be counted toward non-operative trauma); and the vascular system; (Core) IV.A.6.a).(2).(c) A formal rotation in burn care, gynecology, neurological surgery, orthopaedic surgery, cardiac surgery, and urology is not required. Clearly documented goals and objectives must be presented if these components are included as rotations. (Detail) IV.A.6.a).(2).(c).(i) Knowledge of burn physiology and initial burn management is required; (Core)
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No more than 12 months may be devoted to surgical discipline other than the principal components of surgery. (Core)”
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Table 2. General surgery resident TOTAL time in surgical critical care (SCC), trauma and burn rotations (2006-2013). All data are reported as months of training in the SCC-related rotation. ‘Total’ column for percentiles reflects mean of all years. 2007
2008
2009
2010
2011
2012
2013
Total
850
860
889
901
882
865
987
1065
7299
9.9 9.6
10.0 9.9
10.1 9.9
9.9 9.7
9.9 9.6
9.8 9.8
10.0 10.0
10.2 10.0
10.2 10.0
3.6
3.7
3.9
3.8
3.7
3.5
4.1
4.0
3.9
1.0 23.1 5.4 6.9 8.0 8.9 9.6 10.6 11.4 12.9 14.6
1.1 27.6 5.3 7.0 8.0 8.9 9.9 10.7 11.9 13.1 14.9
1.1 28.8 5.1 6.9 8.1 9.0 9.9 10.9 12.0 13.0 15.0
1.0 24.0 5.0 6.9 7.9 8.9 9.7 10.6 11.6 12.7 14.5
0.7 25.4 5.3 6.7 7.9 8.7 9.6 10.5 11.6 12.9 14.6
0.7 22.3 5.4 7.0 8.0 8.9 9.8 10.8 11.5 12.8 14.4
0.0 28.0 5.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 15.0
0.0 27.0 5.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 15.0
0.0 28.8 5.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 15.0
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2006
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Year General Surgery Residents (n) Mean Median Standard Deviation Minimum Maximum 10 20 30 40 Percentiles 50 60 70 80 90
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Table 3. General surgery resident total time in Surgical Critical Care (SCC) rotations (2006-2013). All data are reported as months of training in the SCC rotation. ‘Total’ column for percentiles reflects mean of all years. 2008
2009
2010
2011
2013
850
860
889
901
882
865
987
1065
7299
2.9 2.9
3.0 2.8
2.9 2.9
3.0 2.8
3.1 2.9
3.1 2.9
3.3 3.0
3.2 3.0
3.1 3.0
1.9
2.0
1.8
1.9
1.9
2.9
1.9
2.0
2.0
0.0 14.7 0.0 1.4 2.0 2.1 2.9 3.0 3.7 4.2 5.4
0.0 14.7 0.7 1.5 2.0 2.0 2.8 3.0 3.9 4.5 5.4
0.0 13.8 0.9 1.4 1.9 2.1 2.9 3.0 3.8 4.1 5.4
0.0 12.8 0.9 1.5 2.0 2.4 2.8 3.1 3.8 4.3 5.6
0.0 12.1 1.0 1.8 2.0 2.6 2.9 3.3 3.9 4.5 5.4
0.0 14.0 1.0 2.0 2.0 2.0 3.0 3.0 4.0 5.0 6.0
0.0 14.7 1.0 2.0 2.0 2.0 3.0 3.0 4.0 5.0 6.0
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2007
0.0 12.4 1.0 1.7 2.0 2.5 2.9 3.3 3.9 4.3 5.4
0.0 14.0 1.0 2.0 2.0 3.0 3.0 4.0 4.0 5.0 6.0
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General Surgery Residents (n) Mean Median Standard Deviation Minimum Maximum 10 20 30 40 Percentiles 50 60 70 80 90
2012
Total 20062013
2006
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Table 4. General surgery resident total time in Burn rotations (2006-2013). All data are reported as months of training in the Burn rotation. ‘Total’ column for percentiles reflects mean of all years. 2008
2009
2010
2011
2013
850
860
889
901
882
865
987
1065
7299
0.9 0.9
0.9 0.9
0.8 0.9
0.8 0.9
0.8 0.8
0.8 0.8
0.7 0.9
0.8 1.0
0.8 1.0
1.0
1.0
0.9
0.9
0.9
0.9
0.9
0.9
1.0
0.0 5.0 0.0 0.0 0.0 0.0 0.9 1.0 1.0 1.5 2.3
0.0 5.0 0.0 0.0 0.0 0.0 0.9 1.0 1.0 1.5 2.3
0.0 4.9 0.0 0.0 0.0 0.0 0.9 1.0 1.0 1.4 2.0
0.0 4.9 0.0 0.0 0.0 0.0 0.9 1.0 1.0 1.4 2.0
0.0 5.5 0.0 0.0 0.0 0.0 0.8 1.0 1.0 1.5 2.0
0.0 5.0 0.0 0.0 0.0 0.0 1.0 1.0 1.0 1.0 2.0
0.0 5.5 0.0 0.0 0.0 0.0 1.0 1.0 1.0 1.0 2.0
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2007
0.0 4.9 0.0 0.0 0.0 0.0 0.8 1.0 1.0 1.4 2.1
0.0 5.0 0.0 0.0 0.0 0.0 0.9 1.0 1.0 1.0 2.0
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General Surgery Residents (n) Mean Median Standard Deviation Minimum Maximum 10 20 30 40 Percentiles 50 60 70 80 90
2012
Total 20062013
2006
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Table 5. General surgery resident total time in Trauma rotations (2006-2013). All data are reported as months of training in the Trauma rotation. ‘Total’ column for percentiles reflects mean of all years. 2008
2009
2010
2011
2013
850
860
889
901
882
865
987
1065
7299
6.1 5.9
6.2 6.0
6.4 6.0
6.1 5.7
5.9 5.6
6.0 5.8
6.1 6.0
6.4 6.0
6.3 6.0
3.3
3.5
3.6
3.4
3.3
3.2
3.5
3.6
3.5
0.0 18.1 2.0 3.3 4.3 5.0 5.9 6.6 7.5 8.5 10.3
0.0 24.0 2.0 3.0 4.3 5.2 6.0 6.7 7.4 8.8 10.7
0.0 22.0 2.0 3.6 4.6 5.3 6.0 6.9 7.9 9.0 10.8
0.0 19.8 2.0 3.3 4.1 5.0 5.7 6.4 7.4 8.9 10.4
0.0 21.4 2.0 3.2 4.2 5.0 5.6 6.5 7.4 8.4 10.1
0.0 23.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 11.0
0.0 24.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 11.0
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2007
0.0 20.0 1.9 3.3 4.3 5.0 5.8 6.6 7.5 8.5 10.2
0.0 19.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0
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General Surgery Residents (n) Mean Median Standard Deviation Minimum Maximum 10 20 30 40 Percentiles 50 60 70 80 90
2012
Total 20062013
2006
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Table 6. General surgery resident mean time in SCC, Trauma and Burn rotations (20062013) by Resident level. All data are reported as months of training in the SCC, Trauma and Burn rotations. 2006
2007
2008
2009
2010
2012
Mean 20062013
865
987
1065
1.9 3.2 1.9 2.0 0.9 9.8
2.0 3.3 1.7 2.1 0.9 10.0
2.0 3.4 1.8 2.2 0.9 10.2
0.7 1.9 0.5 0.1 0.0 3.2
0.7 2.0 0.5 0.1 0.0 3.3
0.7 1.9 0.5 0.1 0.0 3.2
0.7 1.9 0.5 0.1 0.0 3.1
1.1 1.1 1.2 1.9 0.9 6.2
1.1 1.0 1.1 2.0 0.9 6.1
1.1 1.1 1.2 2.1 0.9 6.4
1.0 1.1 1.2 2.0 1.0 6.3
0.3 0.4 0.2 0.0 0.0 0.8
0.2 0.3 0.1 0.0 0.0 0.8
0.2 0.4 0.1 0.0 0.0 0.8
0.2 0.4 0.2 0.0 0.0 0.8
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2013
Total residents 7299 1.9 3.3 1.9 2.1 1.0 10.2
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Surgical Critical Care (SCC), Trauma and Burn Rotations General Surgery 850 860 889 901 882 Residents (n) PGY-1 1.7 1.8 1.9 1.8 1.9 PGY-2 3.2 3.2 3.3 3.3 3.3 PGY-3 1.9 1.9 1.9 1.9 1.8 PGY-4 2.0 2.0 2.0 2.0 2.0 PGY-5 1.0 1.1 1.0 1.0 1.0 Total 9.9 10.0 10.1 9.9 9.9 Surgical Critical Care (SCC) Rotations PGY-1 0.6 0.6 0.6 0.7 0.7 PGY-2 1.8 1.8 1.8 1.9 1.9 PGY-3 0.5 0.5 0.5 0.5 0.5 PGY-4 0.1 0.1 0.1 0.1 0.1 PGY-5 0.0 0.0 0.0 0.0 0.0 Total 3.0 3.1 3.0 3.1 3.2 Trauma Rotations PGY-1 0.9 1.0 1.1 1.0 1.0 PGY-2 1.1 1.1 1.2 1.1 1.1 PGY-3 1.2 1.3 1.3 1.2 1.1 PGY-4 2.0 2.0 2.0 2.0 1.9 PGY-5 1.0 1.0 1.0 1.0 1.0 Total 6.2 6.3 6.5 6.3 6.1 Burn Rotations PGY-1 0.2 0.2 0.2 0.2 0.3 PGY-2 0.4 0.4 0.4 0.4 0.4 PGY-3 0.2 0.2 0.2 0.2 0.2 PGY-4 0.0 0.0 0.0 0.0 0.0 PGY-5 0.0 0.0 0.0 0.0 0.0 Total 0.9 0.9 0.8 0.9 0.8
2011
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Table 7. ABSITE Examination Content Outline (SCC 5%, Trauma 6% of Examination content)
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From: http://www.absurgery.org/xfer/GS-ITE.pdf
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Table 8. ABS General Surgery Qualifying Examination Content Outline (SCC 10%, Trauma 8% content)
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From: http://www.absurgery.org/xfer/GS-QE.pdf
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References: 1
Lewis FR, Klingensmith ME. Issues in general surgery residency training--2012. Ann Surg. 2012 Oct;256(4):553-9.
2
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Kelly E, Rogers SO Jr. Graduate medical education in trauma/critical care and acute care surgery: defining goals for a new workforce. Surg Clin North Am. 2012 Aug;92(4):1055-64.
3
Klingensmith ME, Lewis FR. General surgery residency training issues. Adv Surg. 2013;47:251-70. 4
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Napolitano LM, Savarise M, Paramo JC, Soot LC, Todd SR, Gregory J, Timmerman GL, Cioffi WG, Davis E, Sachdeva AK. Are general surgery residents ready to practice? A survey of the American College of Surgeons Board of Governors and Young Fellows Association. J Am Coll Surg. 2014 May;218(5):1063-1072
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Pastores SM, O’Conner MF, Kleinpell R, et al. The Accreditation Council for Graduate Medical Education resident duty hour new standard: history, changes, and impact on staffing of intensive care units. Crit Care Med 2011; 39:2540.
6
Kleinpell R, Ely W, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med 2008;36:2888. 7
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Moote M, Krsek C, Kleinpell R, Todd B. Physician assistants and nurse practitioner utilization in academic medical centers. Am J Med Qual 2011;26:452. http://dx.doi.org/10. 11177/1062860622402984.
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Sirleaf M, Jefferson B, Christmas AB, Sing RF, Thomason MH, Huynh TT. Comparison of procedural complications between resident physicians and advanced clinical providers. J Trauma Acute Care Surg. 2014 Jul;77(1):143-7.
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Kahn SA, Davis SA, Banes CT, Dennis BM, May AK, Gunter OD. Impact of advanced practice providers (nurse practitioners and physician assistants) on surgical residents' critical care experience. J Surg Res. 2015 Nov;199(1):7-12.
ACGME Program Requirements in general surgery. http://www.acgme.org/acgmeweb/portals/0/pfassets/programrequirements/440_general_surgery_ 07012014.pdf; accessed 3/13/2016 11
http://www.absurgery.org/xfer/curriculumoutline2015-16.pdf; accessed 3/13/2016
12
http://www.absurgery.org/default.jsp?aboutsurgerydefined; accessed 3/13/2016
13
http://www.absurgery.org/xfer/GS-ITE.pdf; accessed 3/13/2016
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14
Jones AT, Biester TW, Buyske J, Lewis FR, Malangoni MA. Using the american board of surgery in-training examination to predict board certification: a cautionary study. J Surg Educ. 2014 Nov-Dec;71(6):e144-8. http://www.absurgery.org/xfer/BookletofInfo-Surgery.pdf; accessed 3/13/2016
16
Residency Review Committee (RRC) Newsletter. August 2002.
17
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15
Hui DS, Eastman AL, Lang JL, Frankel HL, O'Keeffe T. A survey of critical care training amongst surgical residents: will they be ready? J Surg Res. 2010 Sep;163(1):132-41.
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Fakhry SM, Watts DD, Michetti C, Hunt JP; EAST Multi-Institutional Blunt Hollow Viscous Injury Research Group. The resident experience on trauma: declining surgical opportunities and career incentives? Analysis of data from a large multi-institutional study. J Trauma. 2003 Jan;54(1):1-7; discussion 7-8. 19
Bulinski P, Bachulis B, Naylor DF Jr, Kam D, Carey M, Dean RE. The changing face of trauma management and its impact on surgical resident training. J Trauma. 2003 Jan;54(1):1613. 20
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Drake FT, Van Eaton EG, Huntington CR, Jurkovich GJ, Aarabi S, Gow KW. ACGME case logs: Surgery resident experience in operative trauma for two decades. J Trauma Acute Care Surg. 2012 Dec;73(6):1500-6. Malangoni MA, Biester TW, Jones AT, Klingensmith ME, Lewis FR Jr. Operative experience of surgery residents: trends and challenges. J Surg Educ. 2013 Nov-Dec;70(6):783-8.
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Drake FT, Horvath KD, Goldin AB, Gow KW. The general surgery chief resident operative experience: 23 years of national ACGME case logs. JAMA Surg. 2013 Sep;148(9):841-7.
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Santry HP, Pringle PL, Collins CE, Kiefe CI. A qualitative analysis of acute care surgery in the United States: it's more than just "a competent surgeon with a sharp knife and a willing attitude". Surgery. 2014 May;155(5):809-25. Santry HP, Madore JC, Collins CE, Ayturk MD, Velmahos GC, Britt LD, Kiefe CI. Variations in the implementation of acute care surgery: results from a national survey of university-affiliated hospitals. J Trauma Acute Care Surg. 2015 Jan;78(1):60-7; discussion 67-8. 25
Cherry-Bukowiec JR1, Miller BS, Doherty GM, Brunsvold ME, Hemmila MR, Park PK, Raghavendran K, Sihler KC, Wahl WL, Wang SC, Napolitano LM. Nontrauma emergency surgery: optimal case mix for general surgery and acute care surgery training. J Trauma. 2011 Nov;71(5):1422-6; discussion 1426-7.
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S0002-9610(16)30415-9
DOI:
10.1016/j.amjsurg.2016.07.016
Reference:
AJS 12027
To appear in:
The American Journal of Surgery
Received Date: 21 January 2016 Revised Date:
25 July 2016
Accepted Date: 29 July 2016
Please cite this article as: Napolitano LM, Biester TW, Jurkovich GJ, Buyske J, Malangoni MA, Lewis Jr. FRMembers of the Trauma, Burns and Critical Care Board of the American Board of Surgery, General Surgery Resident Rotations in Surgical Critical Care, Trauma and Burns: What is Optimal for Residency Training?, The American Journal of Surgery (2016), doi: 10.1016/j.amjsurg.2016.07.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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General Surgery Resident Rotations in Surgical Critical Care, Trauma and Burns: What is Optimal for Residency Training?
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Lena M. Napolitano M.D., FACS Thomas W. Biester M.S. Gregory J. Jurkovich M.D., FACS Jo Buyske M.D., FACS Mark A. Malangoni M.D., FACS Frank R. Lewis Jr. M.D., FACS Members of the Trauma, Burns and Critical Care Board of the American Board of Surgery
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For submission to American Journal of Surgery, AWS Edition Original Article; Tables 8; References 25 Short title: Resident Training in Critical Care, Trauma & Burns (43 characters) Keywords: surgical critical care, trauma, burn, general surgery, resident, rotation, duration, general surgery residency training The authors have no conflict of interest. No funding support for this work.
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Members of the Trauma, Burns and Critical Care Board of the American Board of Surgery Roxie M. Albrecht, M.D., FACS Karen J. Brasel, M.D., FACS Eileen M. Bulger, M.D., FACS Martin A. Croce, M.D., FACS David G. Greenhalgh, M.D., FACS Pamela A. Lipsett, M.D., FACS Frederick A. Luchette, M.D., FACS Robert C. Mackersie, M.D., FACS Anne G. Rizzo, M.D., FACS Ronald M. Stewart, M.D., FACS David A. Spain, M.D., FACS
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Corresponding author: Lena M. Napolitano MD, FACS, FCCP, FCCM Professor of Surgery Division Chief, Acute Care Surgery [Trauma, Burns, Critical Care, Emergency Surgery] Director, Trauma and Surgical Critical Care Associate Chair, Department of Surgery 1C421 University Hospital, Box 0033 1500 E. Medical Center Drive Ann Arbor, MI 48109-0033 Phone 734-615-4775 Fax 734-936-9657 Email [email protected] 1
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ABSTRACT Background: There are no specific ACGME General Surgery Residency Program Requirements for rotations in surgical critical care (SCC), trauma and burn. We sought to
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determine the experience of general surgery residents in SCC, trauma and burn rotations.
Methods: Data analysis of surgical rotations of American Board of Surgery (ABS) general surgery resident applicants (n=7299) for the last 8 years (2006-2013, inclusive) was performed
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through electronic applications to the ABS Qualifying Examination (QE). Duration (months) spent in SCC, trauma and burn rotations, and post-graduate year (PGY) level were examined.
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Results: The mean/median total months in SCC, trauma and burn rotations was 10.2/10.0 (SD 3.9 months), representing approximately 16.7% (10 of 60 months) of a general surgery resident’s training. However, there was great variability (range 0-29 months). Mean/median SCC rotation duration was 3.1/3.0 months (SD 2, min-max 0-15), 6.3/6.0 months (SD 3.5, min-max 0-24) for
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trauma and 0.8/1.0 months (SD 1.0, min-max 0-6) for burn. Of the total mean 10.2 months duration, the longest exposure was 2 months as PGY-1, 3.4 months as PGY-2, 1.9 months as PGY-3, 2.2 months as PGY-4 and 1.1 months as PGY-5 . PGY-5 residents spent a mean of 1
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month in SCC, trauma and burn rotations. PGY-4/5 residents spent the majority of this total time in trauma rotations, whereas junior residents (PGY-1-3) in SCC and trauma rotations.
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Conclusion: There is significant variability in total duration of SCC, trauma and burn rotations and PGY level in U.S. general surgery residency programs, which may result in significant variability in the fund of knowledge and clinical experience of the trainee completing general surgery residency training. As acute care surgery programs have begun to integrate emergency general surgery with SCC, trauma and burn rotations, it is an ideal time to determine the optimal curriculum and duration of these important rotations for general surgery residency training.
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General Surgery Resident Rotations in Surgical Critical Care, Trauma and Burns: What is Optimal for Residency Training?
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Lena M. Napolitano M.D., FACS Thomas W. Biester M.S. Gregory J. Jurkovich M.D., FACS Jo Buyske M.D., FACS Mark A. Malangoni M.D., FACS Frank R. Lewis Jr. M.D., FACS Members of the Trauma, Burns and Critical Care Board of the American Board of Surgery
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Original Article; Tables 8; References 25 Short title: Resident Training in Critical Care, Trauma & Burns (43 characters) Keywords: surgical critical care, trauma, burn, general surgery, resident, rotation, duration, general surgery residency training The authors have no conflict of interest. No funding support for this work.
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Members of the Trauma, Burns and Critical Care Board of the American Board of Surgery Roxie M. Albrecht, M.D., FACS Karen J. Brasel, M.D., FACS Eileen M. Bulger, M.D., FACS Martin A. Croce, M.D., FACS David G. Greenhalgh, M.D., FACS Pamela A. Lipsett, M.D., FACS Frederick A. Luchette, M.D., FACS Robert C. Mackersie, M.D., FACS Anne G. Rizzo, M.D., FACS Ronald M. Stewart, M.D., FACS David A. Spain, M.D., FACS
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Corresponding author: Lena M. Napolitano MD, FACS, FCCP, FCCM Professor of Surgery Division Chief, Acute Care Surgery [Trauma, Burns, Critical Care, Emergency Surgery] Director, Trauma and Surgical Critical Care Associate Chair, Department of Surgery 1C421 University Hospital, Box 0033 1500 E. Medical Center Drive Ann Arbor, MI 48109-0033 Phone 734-615-4775 Fax 734-936-9657 Email: [email protected]
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ABSTRACT Background: There are no specific ACGME General Surgery Residency Program Requirements for rotations in surgical critical care (SCC), trauma and burn. We sought to
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determine the experience of general surgery residents in SCC, trauma and burn rotations.
Methods: Data analysis of surgical rotations of American Board of Surgery (ABS) general surgery resident applicants (n=7299) for the last 8 years (2006-2013, inclusive) was performed
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through electronic applications to the ABS Qualifying Examination (QE). Duration (months) spent in SCC, trauma and burn rotations, and post-graduate year (PGY) level were examined.
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Results: The mean/median total months in SCC, trauma and burn rotations was 10.2/10.0 (SD 3.9 months), representing approximately 16.7% (10 of 60 months) of a general surgery resident’s training. However, there was great variability (range 0-29 months). Mean/median SCC rotation duration was 3.1/3.0 months (SD 2, min-max 0-15), 6.3/6.0 months (SD 3.5, min-max 0-24) for
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trauma and 0.8/1.0 months (SD 1.0, min-max 0-6) for burn. Of the total mean 10.2 months duration, the longest exposure was 2 months as PGY-1, 3.4 months as PGY-2, 1.9 months as PGY-3, 2.2 months as PGY-4 and 1.1 months as PGY-5 . PGY-5 residents spent a mean of 1
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month in SCC, trauma and burn rotations. PGY-4/5 residents spent the majority of this total time in trauma rotations, whereas junior residents (PGY-1-3) in SCC and trauma rotations.
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Conclusion: There is significant variability in total duration of SCC, trauma and burn rotations and PGY level in U.S. general surgery residency programs, which may result in significant variability in the fund of knowledge and clinical experience of the trainee completing general surgery residency training. As acute care surgery programs have begun to integrate emergency general surgery with SCC, trauma and burn rotations, it is an ideal time to determine the optimal curriculum and duration of these important rotations for general surgery residency training.
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INTRODUCTION The Trauma, Burns and Critical Care Board of the American Board of Surgery has been concerned that our current resident training paradigm in General Surgery potentially provides
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inadequate experience and clinical rotations in surgical critical care (SCC), trauma and burns which is necessary for optimal care of our surgical patients. 1 2 3 There is also considerable
concern that graduating residents are not adequately prepared for independent surgical practice. 4
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Since the Accreditation Council for Graduate Medical Education (ACGME) mandated a significant reduction in resident work hours, physician manpower in more labor-intense units
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(such as intensive care units) has transitioned to advanced practice providers to provide patient care and procedures. 5 6 7 8 Increased utilization of advanced practice providers may have a negative impact on surgical resident education and experience in surgical critical care. 9 The current ACGME General Surgery Residency Program Requirements 10 are quite vague with
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regard to the optimal time required in SCC, trauma and burn rotations during general surgery residency (Table 1). National efforts to reform general surgery residency education have been ongoing, but a critical analysis of the specific general surgery residency rotation requirements in
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SCC, trauma and burns has not yet been addressed. We sought to determine the experience of general surgery residents in SCC, trauma and
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burns during their general surgery residency training and examined the duration of rotations in these areas and the specific PGY-level when they occurred for general surgery residents.
METHODS
We analyzed de-identified data of the surgical rotations of applicants to the American Board of Surgery (ABS) Qualifying Examination (QE) over an eight (8) year period, from 2006-
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2013, inclusive. General surgery resident rotation data submitted through electronic applications were examined. We determined the number of months spent in SCC, trauma and burn rotations, and at what post-graduate year (PGY) level for general surgery residents using candidate rotation
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lists and analyzed by the ABS psychometrician (TWB).
Data from the ABS electronic applications were self-reported. Residents indicated the beginning/end and location (hospital) of the rotation, and chose a rotation description from a
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drop-down menu included on the ABS QE application form. The instructions on the ABS QE application form are: “You must list chronologically all rotations and activities from the
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beginning of residency, including all time away from training (including time taken for vacation, interviews, medical leave, visa issues, and early departures for fellowships). Each rotation must be listed separately by clinical activity, not grouped together as a yearly total.” There were 3 rotations of interest included on the ABS QE application: (1) SCC (logged
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as ICU-SICU on QE application); (2) Trauma; and (3) Burns. Records were excluded for (1) residents who recorded less than 5 years of rotation experience (e.g., those who received credit for foreign training) or more than five years of clinical activity (e.g., transfers, remedial/repeat
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years), (2) residents who did not accurately complete the rotations section of the QE application and (3) residents who completed their training during this time period but never applied for the
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ABS QE. Records were available for 7299 of 8676 general surgery residents who completed their training over the 8-year period (84.1% of all residents). Statistical Analysis: Descriptive statistics [mean, median, standard deviation (SD)] were used to report the total months of experience in SCC, trauma and burns rotations for general surgery residents as a group, and by specific post-graduate year.
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RESULTS Table 2 reports residents’ total months in all SCC, trauma and burn rotations during general surgery residency. The mean number of months in SCC, trauma and burn rotations for
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general surgery residents was 10.2 months (SD 3.9 months), representing approximately 16.7% (10 of 60 months) of residency training. However, there was wide variability reported, as
reflected by the minimum-maximum range of 0 to 29 months. It should be noted that the mean
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total number of months has been constant over this 8-year period with no downward trend. Table 3 reports residents’ total months in SCC rotations during general surgery
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residency. The mean number of months in SCC rotations was 3.1 months (SD 2 months), with a minimum-maximum range of 0 to 15 months.
Table 4 reports residents’ total months in Burn rotations during general surgery residency. The mean number of months in Burn rotations was 0.8 months (SD 1.0 months), with
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a minimum-maximum range of 0 to 6 months.
Table 5 reports residents’ total months in Trauma rotations during general surgery residency. The mean number of months in Trauma rotations was 6.3 months (SD 3.5 months),
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with a minimum-maximum range of 0 to 24 months. Table 6 provides data regarding general surgery resident rotation in SCC, trauma and
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burn by resident post-graduate year. Of the total mean 10.2 months duration in these rotations by general surgery residents, the longest mean exposure was 2 months as PGY-1, 3.4 months as PGY-2, 1.9 months as PGY-3, 2.2 months as PGY-4 and 1.1 months as PGY-5. PGY-5 residents spent a mean of 1 month in SCC, trauma and burn rotations. PGY-4/5 residents spent the majority of this total time in trauma rotations, whereas junior residents (PGY-1-3) spent the majority of this total time in SCC and trauma rotations.
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DISCUSSION In this study, we have identified that there is significant variability in the duration of rotations in SCC, trauma and burn during general surgery residency. It is unclear whether the
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current rotations provide competency-based education to meet the SCORE Curriculum General Surgery requirements in these three areas (SCC, trauma and burn). Almost all of the SCORE modules in these three areas are delineated as “core” patient care topics. 11
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Since one of the goals of general surgery residency training is to prepare for initial board certification in general surgery, then optimal duration in these rotations should prepare residents
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to meet the ABS requirements, including the ABSITE, Qualifying Examination (QE) and Certifying Examination (CE). The ABS states that residency training in general surgery requires experience in all of the following content areas, including SCC, trauma and burn 12: Alimentary Tract (including Bariatric Surgery); Abdomen and its Contents; Breast, Skin and Soft Tissue;
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Endocrine System; Solid Organ Transplantation; Pediatric Surgery; Surgical Critical Care; Surgical Oncology (including Head and Neck Surgery); Trauma/Burns and Emergency Surgery and Vascular Surgery.
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In the ABSITE, 5% of the questions are related to the category of SCC and 6% of questions are in the category of Trauma (Table 7). 13 Therefore a total of 11% of questions in
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the ABSITE are in the categories of SCC, trauma and burn knowledge. The number of questions related to SCC and Trauma on the ABSITE has significantly decreased compared to prior years. It has been documented that ABSITE scores are a useful predictor of QE scores and outcomes, but do not predict passing the CE. 14 The ABS' minimum requirements for the QE application are 750 procedures in five years and 150 in the chief senior year, with an overall balanced distribution of cases. Residents may
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count up to 50 cases as teaching assistant toward the 750 total; however these cases may not be counted toward the 150 chief year cases. Applicants who finish residency in 2009-2010 and thereafter must also list at least 25
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cases in surgical critical care, with a minimum of one in each of the area’s 7 categories. 15 The Critical Care Index Cases (CCIC) log was developed to provide documentation of resident
management of a broad scope of critical care patients as follows: Each resident must develop a
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log of at least 25 critical care patients who represent the broad scope of critical care index
the following 7 categories:
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management. Each of the patients listed in the log should include the management of at least 2 of
•8410 - Ventilator Management (>24 hours on a ventilator)
•8420 - Hemorrhage (a non-trauma patient requiring more than 3 units of blood/products and monitoring in ICU settings)
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•8430 - Hemodynamic Instability requiring vasoactive/inotropic agents •8440 - Organ Failure (i.e., renal, hepatic, endocrine, CNS, cardiac failure) •8450 - Dysrhythmias (requiring drug management) •8460 - Invasive Monitors (Pulmonary artery catheter, central venous line, arterial line,
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Intracranial Pressure monitor/continuous EEG/LICOX/Jugular Bulb oximetry)
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•8470 – Nutritional support (Parenteral/Enteral Nutrition Cases must also be reported for operative and nonoperative trauma. Prior to 2003, the
RRC requirement was 16 trauma operative cases. 16 Since 2003-2004, the RRC has required general surgery residency graduates must have a minimum of 30 trauma cases for graduation. Of the 30 required cases, 10 will be the minimum number of operative trauma cases; 20 will be the minimum number of non-operative cases which are recorded using the CPT code 99199.
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In the ABS QE, 10% of the questions are related to the category of SCC, and 8% of questions are in the category of Trauma (Table 8). Therefore a total of 18% of the questions in the ABS QE are in the categories of SCC, trauma and burn knowledge.
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In order to provide optimal patient care, and to meet these ABS requirements for
certification, what is the optimal duration of rotations in SCC, trauma and burns for general surgery residents? How can we ensure that the SCORE standardized curriculum content in these
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areas is completed during these rotations for competency-based resident advancement? Little data are available in the published peer-reviewed literature regarding this topic of optimal
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general surgery residency training and optimal rotation duration in SCC, trauma and burn surgery.
A single-institution study distributed anonymous surveys to categorical general surgery residents in their large, university-based residency program to measure the residents’ experience
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in surgical critical care. 17 At the time of the survey, 52 respondents had completed 9.3±4.5 weeks of SCC rotations. Despite no rotations beyond PGY3, senior residents (PGYs 4/5) reported significantly greater SCC training time (13.1 vs. 7.8 weeks) and comfort managing SCC
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diseases and procedures than juniors (PGY 3). The mean education satisfaction score was 3.9 +/- 0.9 (5 = extremely satisfied). Residents anticipated performing minimal SCC management of
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their own patients, but most felt that SCC-trained surgeons should manage critically-ill surgery patients. Senior residents reported greater SCC fellowship interest (19% versus 0%). The addition of acute care surgery increased interest in 30% of respondents. The authors concluded that senior residents reported greater comfort with SCC management despite the lack of senior SCC rotations, while dedicated SCC training time for junior residents appears to be declining.
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Regarding general surgery residents’ rotation in trauma surgery, the resident experience has substantially changed related to increasing nonoperative management of trauma patients, especially for abdominal solid organ injuries. Data from a large multicenter (82 trauma centers
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representing over 247,000 trauma admissions) study documented that surgical resident
experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of major operative procedures. They reported that assuming 1 night of 4
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on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, and the resident will care for an
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average of 500 blunt trauma patients before performing a splenectomy or liver repair. 18 Another report from two ACS-verified trauma centers documented that 85% (370 of 434) of trauma patients were managed without an index trauma surgical procedure according to RRC guidelines. Only 14.7% (64 of 434) of patients underwent operative intervention that qualified as
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an index trauma surgical case identified by the RRC, with an average of 6.4 trauma cases per chief resident. The spleen and small bowel were the two most commonly injured organs found at laparotomy. Nonoperative intervention of many patients with solid abdominal organ injuries did
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not meet the operation requirements expected by the RRC. 19 A recent study analyzed the reported volume of operative trauma to examine nationwide
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trends over the last two decades. The ACGME database of operative logs was queried from academic year 1989-1990 to 2009-2010 to identify shifts in trauma operative experience and examined in four 5-year blocks. Significant declines in ACGME-designated trauma cases was identified in the four 5-year blocks (75.5 vs. 54.5 vs. 39.3 vs. 39.4 cases, p<0.001). In comparison, overall general surgery caseload increased from the first to second block, but decreased in the last two most recent blocks. This study confirmed that recent general surgery
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trainees performed fewer trauma operations than previous trainees [31 abdominal trauma operations (5 spleen, 4 liver) in first block compared to 17 abdominal trauma operations (3 20
Additional studies confirm these findings of reduced
trauma operative experience for general surgery residents.
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spleen, 2 liver) in most recent block].
The data from this current study document significant variability both in duration and specific PGY-level for SCC, trauma and burn rotations. Since SCC, trauma and burn are
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essential content areas of general surgery, this significant variability is not ideal as it may result in significant differences in both fund of knowledge and clinical experience in the care of these
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specific patients for senior surgery trainees completing general surgery residency. Furthermore, it may impact on ABS certification success. Future research should investigate whether general surgery residents who have longer duration in SCC, trauma and burn rotations perform better on the ABSITE, QE and CE examinations, and determine whether this is related to improved
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performance in the specific content areas relevant to these surgical rotations. There are some limitations to this study. Some residents may designate SCC, trauma and/or burn rotations simply as “General Surgery” and it is possible that some of their specific
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experience in these three areas may be underestimated. Furthermore, coding errors in the resident entries regarding their residency rotations were possible.
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In addition to the important finding of wide variability both in duration and specific
PGY-level for SCC, trauma and burn rotations, we recognize that many programs have now established an acute care surgery model 23 24 25which integrates emergency general surgery into SCC, trauma and/or burn rotations. Given the findings of this study and the reorganization into acute care surgery for many institutions, the time is ideal to standardize curriculum content and determine optimal duration of these important rotations for general surgery residency training for
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competency-based advancement in SCC, trauma and burn. The Trauma, Burns and Critical Care Board of the ABS is currently in discussion regarding optimal competency-based general surgery
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residency training in the areas of SCC, trauma and burns.
CONCLUSION:
There is significant variability in total duration of SCC, trauma and burn rotations and PGY level
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in U.S. general surgery residency programs, which may result in significant variability in the fund of knowledge and clinical experience of the trainee completing general surgery residency
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training. As acute care surgery programs have begun to integrate emergency general surgery with SCC, trauma and burn rotations, it is an ideal time to determine the optimal curriculum and
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duration of these important rotations for general surgery residency training.
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Table 1. ACGME Program Requirements for General Surgery Residency Training “IV.A.6.a).(2) The 60-month clinical program should be organized as follows: (Core)
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IV.A.6.a).(2).(a) At least 54 months of the 60-month program must be spent on clinical assignments in surgery, with documented experience in emergency care and surgical critical care in order to enable residents to manage patients with severe and complex illnesses and with major injuries. (Core)
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IV.A.6.a).(2).(b) 42 months of these 54 months must be spent on clinical assignments in the essential content areas of surgery. (Core) IV.A.6.a).(2).(b).(i) The essential content areas are: the abdomen and its contents; the alimentary tract; skin, soft tissues, and breast; endocrine surgery; head and neck surgery; pediatric surgery; surgical critical care; surgical oncology; trauma and nonoperative trauma (burn experience that includes patient management may be counted toward non-operative trauma); and the vascular system; (Core) IV.A.6.a).(2).(c) A formal rotation in burn care, gynecology, neurological surgery, orthopaedic surgery, cardiac surgery, and urology is not required. Clearly documented goals and objectives must be presented if these components are included as rotations. (Detail) IV.A.6.a).(2).(c).(i) Knowledge of burn physiology and initial burn management is required; (Core)
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No more than 12 months may be devoted to surgical discipline other than the principal components of surgery. (Core)”
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Table 2. General surgery resident TOTAL time in surgical critical care (SCC), trauma and burn rotations (2006-2013). All data are reported as months of training in the SCC-related rotation. ‘Total’ column for percentiles reflects mean of all years. 2007
2008
2009
2010
2011
2012
2013
Total
850
860
889
901
882
865
987
1065
7299
9.9 9.6
10.0 9.9
10.1 9.9
9.9 9.7
9.9 9.6
9.8 9.8
10.0 10.0
10.2 10.0
10.2 10.0
3.6
3.7
3.9
3.8
3.7
3.5
4.1
4.0
3.9
1.0 23.1 5.4 6.9 8.0 8.9 9.6 10.6 11.4 12.9 14.6
1.1 27.6 5.3 7.0 8.0 8.9 9.9 10.7 11.9 13.1 14.9
1.1 28.8 5.1 6.9 8.1 9.0 9.9 10.9 12.0 13.0 15.0
1.0 24.0 5.0 6.9 7.9 8.9 9.7 10.6 11.6 12.7 14.5
0.7 25.4 5.3 6.7 7.9 8.7 9.6 10.5 11.6 12.9 14.6
0.7 22.3 5.4 7.0 8.0 8.9 9.8 10.8 11.5 12.8 14.4
0.0 28.0 5.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 15.0
0.0 27.0 5.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 15.0
0.0 28.8 5.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 15.0
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2006
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Year General Surgery Residents (n) Mean Median Standard Deviation Minimum Maximum 10 20 30 40 Percentiles 50 60 70 80 90
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Table 3. General surgery resident total time in Surgical Critical Care (SCC) rotations (2006-2013). All data are reported as months of training in the SCC rotation. ‘Total’ column for percentiles reflects mean of all years. 2008
2009
2010
2011
2013
850
860
889
901
882
865
987
1065
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2.9 2.9
3.0 2.8
2.9 2.9
3.0 2.8
3.1 2.9
3.1 2.9
3.3 3.0
3.2 3.0
3.1 3.0
1.9
2.0
1.8
1.9
1.9
2.9
1.9
2.0
2.0
0.0 14.7 0.0 1.4 2.0 2.1 2.9 3.0 3.7 4.2 5.4
0.0 14.7 0.7 1.5 2.0 2.0 2.8 3.0 3.9 4.5 5.4
0.0 13.8 0.9 1.4 1.9 2.1 2.9 3.0 3.8 4.1 5.4
0.0 12.8 0.9 1.5 2.0 2.4 2.8 3.1 3.8 4.3 5.6
0.0 12.1 1.0 1.8 2.0 2.6 2.9 3.3 3.9 4.5 5.4
0.0 14.0 1.0 2.0 2.0 2.0 3.0 3.0 4.0 5.0 6.0
0.0 14.7 1.0 2.0 2.0 2.0 3.0 3.0 4.0 5.0 6.0
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0.0 12.4 1.0 1.7 2.0 2.5 2.9 3.3 3.9 4.3 5.4
0.0 14.0 1.0 2.0 2.0 3.0 3.0 4.0 4.0 5.0 6.0
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General Surgery Residents (n) Mean Median Standard Deviation Minimum Maximum 10 20 30 40 Percentiles 50 60 70 80 90
2012
Total 20062013
2006
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Table 4. General surgery resident total time in Burn rotations (2006-2013). All data are reported as months of training in the Burn rotation. ‘Total’ column for percentiles reflects mean of all years. 2008
2009
2010
2011
2013
850
860
889
901
882
865
987
1065
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0.9 0.9
0.9 0.9
0.8 0.9
0.8 0.9
0.8 0.8
0.8 0.8
0.7 0.9
0.8 1.0
0.8 1.0
1.0
1.0
0.9
0.9
0.9
0.9
0.9
0.9
1.0
0.0 5.0 0.0 0.0 0.0 0.0 0.9 1.0 1.0 1.5 2.3
0.0 5.0 0.0 0.0 0.0 0.0 0.9 1.0 1.0 1.5 2.3
0.0 4.9 0.0 0.0 0.0 0.0 0.9 1.0 1.0 1.4 2.0
0.0 4.9 0.0 0.0 0.0 0.0 0.9 1.0 1.0 1.4 2.0
0.0 5.5 0.0 0.0 0.0 0.0 0.8 1.0 1.0 1.5 2.0
0.0 5.0 0.0 0.0 0.0 0.0 1.0 1.0 1.0 1.0 2.0
0.0 5.5 0.0 0.0 0.0 0.0 1.0 1.0 1.0 1.0 2.0
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2007
0.0 4.9 0.0 0.0 0.0 0.0 0.8 1.0 1.0 1.4 2.1
0.0 5.0 0.0 0.0 0.0 0.0 0.9 1.0 1.0 1.0 2.0
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General Surgery Residents (n) Mean Median Standard Deviation Minimum Maximum 10 20 30 40 Percentiles 50 60 70 80 90
2012
Total 20062013
2006
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Table 5. General surgery resident total time in Trauma rotations (2006-2013). All data are reported as months of training in the Trauma rotation. ‘Total’ column for percentiles reflects mean of all years. 2008
2009
2010
2011
2013
850
860
889
901
882
865
987
1065
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6.1 5.9
6.2 6.0
6.4 6.0
6.1 5.7
5.9 5.6
6.0 5.8
6.1 6.0
6.4 6.0
6.3 6.0
3.3
3.5
3.6
3.4
3.3
3.2
3.5
3.6
3.5
0.0 18.1 2.0 3.3 4.3 5.0 5.9 6.6 7.5 8.5 10.3
0.0 24.0 2.0 3.0 4.3 5.2 6.0 6.7 7.4 8.8 10.7
0.0 22.0 2.0 3.6 4.6 5.3 6.0 6.9 7.9 9.0 10.8
0.0 19.8 2.0 3.3 4.1 5.0 5.7 6.4 7.4 8.9 10.4
0.0 21.4 2.0 3.2 4.2 5.0 5.6 6.5 7.4 8.4 10.1
0.0 23.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 11.0
0.0 24.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 11.0
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2007
0.0 20.0 1.9 3.3 4.3 5.0 5.8 6.6 7.5 8.5 10.2
0.0 19.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0
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General Surgery Residents (n) Mean Median Standard Deviation Minimum Maximum 10 20 30 40 Percentiles 50 60 70 80 90
2012
Total 20062013
2006
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Table 6. General surgery resident mean time in SCC, Trauma and Burn rotations (20062013) by Resident level. All data are reported as months of training in the SCC, Trauma and Burn rotations. 2006
2007
2008
2009
2010
2012
Mean 20062013
865
987
1065
1.9 3.2 1.9 2.0 0.9 9.8
2.0 3.3 1.7 2.1 0.9 10.0
2.0 3.4 1.8 2.2 0.9 10.2
0.7 1.9 0.5 0.1 0.0 3.2
0.7 2.0 0.5 0.1 0.0 3.3
0.7 1.9 0.5 0.1 0.0 3.2
0.7 1.9 0.5 0.1 0.0 3.1
1.1 1.1 1.2 1.9 0.9 6.2
1.1 1.0 1.1 2.0 0.9 6.1
1.1 1.1 1.2 2.1 0.9 6.4
1.0 1.1 1.2 2.0 1.0 6.3
0.3 0.4 0.2 0.0 0.0 0.8
0.2 0.3 0.1 0.0 0.0 0.8
0.2 0.4 0.1 0.0 0.0 0.8
0.2 0.4 0.2 0.0 0.0 0.8
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Total residents 7299 1.9 3.3 1.9 2.1 1.0 10.2
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Surgical Critical Care (SCC), Trauma and Burn Rotations General Surgery 850 860 889 901 882 Residents (n) PGY-1 1.7 1.8 1.9 1.8 1.9 PGY-2 3.2 3.2 3.3 3.3 3.3 PGY-3 1.9 1.9 1.9 1.9 1.8 PGY-4 2.0 2.0 2.0 2.0 2.0 PGY-5 1.0 1.1 1.0 1.0 1.0 Total 9.9 10.0 10.1 9.9 9.9 Surgical Critical Care (SCC) Rotations PGY-1 0.6 0.6 0.6 0.7 0.7 PGY-2 1.8 1.8 1.8 1.9 1.9 PGY-3 0.5 0.5 0.5 0.5 0.5 PGY-4 0.1 0.1 0.1 0.1 0.1 PGY-5 0.0 0.0 0.0 0.0 0.0 Total 3.0 3.1 3.0 3.1 3.2 Trauma Rotations PGY-1 0.9 1.0 1.1 1.0 1.0 PGY-2 1.1 1.1 1.2 1.1 1.1 PGY-3 1.2 1.3 1.3 1.2 1.1 PGY-4 2.0 2.0 2.0 2.0 1.9 PGY-5 1.0 1.0 1.0 1.0 1.0 Total 6.2 6.3 6.5 6.3 6.1 Burn Rotations PGY-1 0.2 0.2 0.2 0.2 0.3 PGY-2 0.4 0.4 0.4 0.4 0.4 PGY-3 0.2 0.2 0.2 0.2 0.2 PGY-4 0.0 0.0 0.0 0.0 0.0 PGY-5 0.0 0.0 0.0 0.0 0.0 Total 0.9 0.9 0.8 0.9 0.8
2011
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Table 7. ABSITE Examination Content Outline (SCC 5%, Trauma 6% of Examination content)
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From: http://www.absurgery.org/xfer/GS-ITE.pdf
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Table 8. ABS General Surgery Qualifying Examination Content Outline (SCC 10%, Trauma 8% content)
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From: http://www.absurgery.org/xfer/GS-QE.pdf
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References: 1
Lewis FR, Klingensmith ME. Issues in general surgery residency training--2012. Ann Surg. 2012 Oct;256(4):553-9.
2
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Kelly E, Rogers SO Jr. Graduate medical education in trauma/critical care and acute care surgery: defining goals for a new workforce. Surg Clin North Am. 2012 Aug;92(4):1055-64.
3
Klingensmith ME, Lewis FR. General surgery residency training issues. Adv Surg. 2013;47:251-70. 4
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Napolitano LM, Savarise M, Paramo JC, Soot LC, Todd SR, Gregory J, Timmerman GL, Cioffi WG, Davis E, Sachdeva AK. Are general surgery residents ready to practice? A survey of the American College of Surgeons Board of Governors and Young Fellows Association. J Am Coll Surg. 2014 May;218(5):1063-1072
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5
Pastores SM, O’Conner MF, Kleinpell R, et al. The Accreditation Council for Graduate Medical Education resident duty hour new standard: history, changes, and impact on staffing of intensive care units. Crit Care Med 2011; 39:2540.
6
Kleinpell R, Ely W, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med 2008;36:2888. 7
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Moote M, Krsek C, Kleinpell R, Todd B. Physician assistants and nurse practitioner utilization in academic medical centers. Am J Med Qual 2011;26:452. http://dx.doi.org/10. 11177/1062860622402984.
9
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Sirleaf M, Jefferson B, Christmas AB, Sing RF, Thomason MH, Huynh TT. Comparison of procedural complications between resident physicians and advanced clinical providers. J Trauma Acute Care Surg. 2014 Jul;77(1):143-7.
10
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Kahn SA, Davis SA, Banes CT, Dennis BM, May AK, Gunter OD. Impact of advanced practice providers (nurse practitioners and physician assistants) on surgical residents' critical care experience. J Surg Res. 2015 Nov;199(1):7-12.
ACGME Program Requirements in general surgery. http://www.acgme.org/acgmeweb/portals/0/pfassets/programrequirements/440_general_surgery_ 07012014.pdf; accessed 3/13/2016 11
http://www.absurgery.org/xfer/curriculumoutline2015-16.pdf; accessed 3/13/2016
12
http://www.absurgery.org/default.jsp?aboutsurgerydefined; accessed 3/13/2016
13
http://www.absurgery.org/xfer/GS-ITE.pdf; accessed 3/13/2016
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14
Jones AT, Biester TW, Buyske J, Lewis FR, Malangoni MA. Using the american board of surgery in-training examination to predict board certification: a cautionary study. J Surg Educ. 2014 Nov-Dec;71(6):e144-8. http://www.absurgery.org/xfer/BookletofInfo-Surgery.pdf; accessed 3/13/2016
16
Residency Review Committee (RRC) Newsletter. August 2002.
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15
Hui DS, Eastman AL, Lang JL, Frankel HL, O'Keeffe T. A survey of critical care training amongst surgical residents: will they be ready? J Surg Res. 2010 Sep;163(1):132-41.
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Fakhry SM, Watts DD, Michetti C, Hunt JP; EAST Multi-Institutional Blunt Hollow Viscous Injury Research Group. The resident experience on trauma: declining surgical opportunities and career incentives? Analysis of data from a large multi-institutional study. J Trauma. 2003 Jan;54(1):1-7; discussion 7-8. 19
Bulinski P, Bachulis B, Naylor DF Jr, Kam D, Carey M, Dean RE. The changing face of trauma management and its impact on surgical resident training. J Trauma. 2003 Jan;54(1):1613. 20
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Drake FT, Van Eaton EG, Huntington CR, Jurkovich GJ, Aarabi S, Gow KW. ACGME case logs: Surgery resident experience in operative trauma for two decades. J Trauma Acute Care Surg. 2012 Dec;73(6):1500-6. Malangoni MA, Biester TW, Jones AT, Klingensmith ME, Lewis FR Jr. Operative experience of surgery residents: trends and challenges. J Surg Educ. 2013 Nov-Dec;70(6):783-8.
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Drake FT, Horvath KD, Goldin AB, Gow KW. The general surgery chief resident operative experience: 23 years of national ACGME case logs. JAMA Surg. 2013 Sep;148(9):841-7.
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Santry HP, Pringle PL, Collins CE, Kiefe CI. A qualitative analysis of acute care surgery in the United States: it's more than just "a competent surgeon with a sharp knife and a willing attitude". Surgery. 2014 May;155(5):809-25. Santry HP, Madore JC, Collins CE, Ayturk MD, Velmahos GC, Britt LD, Kiefe CI. Variations in the implementation of acute care surgery: results from a national survey of university-affiliated hospitals. J Trauma Acute Care Surg. 2015 Jan;78(1):60-7; discussion 67-8. 25
Cherry-Bukowiec JR1, Miller BS, Doherty GM, Brunsvold ME, Hemmila MR, Park PK, Raghavendran K, Sihler KC, Wahl WL, Wang SC, Napolitano LM. Nontrauma emergency surgery: optimal case mix for general surgery and acute care surgery training. J Trauma. 2011 Nov;71(5):1422-6; discussion 1426-7.
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