- Email: [email protected]
Resident and Attending Perceptions of Resident Involvement: An Analysis of ACGME Reporting Guidelines
ORIGINAL REPORTS
Resident and Attending Perceptions of Resident Involvement: An Analysis of ACGME Reporting Guidelines Ryan Morgan, BS, Douglas F. Kauffman, PhD, Gerard Doherty, MD and Teviah Sachs, MD, MPH Department of Surgery, Boston University School of Medicine, Boston, Massachusetts OBJECTIVE: For general surgery residents (Residents) to log an operation, the ACGME requires “significant involvement” in diagnosis (DX), operation selection (SEL), operation (OPR), preoperative (PRE), and postoperative (POC) care. We compared how residents and attending surgeons (Attendings) perceived residents’ role in each of these core requirements.
answers, residents generally overstated their contribution to the DX (68%), PRE (58%), and SEL (64%) but understated their contribution in OPR (63%) and POC (62%).
postoperatively regarding responsibility for each core requirement on a 5-point Likert scale from “Completely Attending” to “Completely Resident.” Significance was determined using Chi-square analysis (p o 0.05) and degree of agreement was calculated using Spearman’s rank correlation (rs).
CONCLUSIONS: Residents and attendings demonstrated reliable agreement for most core requirements, but residents were often unable to be involved in all 5 core requirements. Resident involvement was weighted toward later stages of patient care, yet residents often underestimated their contributions. Operational acuity, complexity, and attending experience correlated with resident operative involvement. C 2016 Association of Program ( J Surg Ed ]:]]]-]]]. J Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
SETTING: Boston Medical Center, Boston, MA (tertiary
KEY WORDS: resident education, surgical training, resi-
institution).
dent perception, case log, ACGME, attending agreement
RESULTS: A total of 302 paired surveys were analyzed.
COMPETENCIES:
DESIGN: Residents and attendings completed surveys
Residents more often performed a significant portion of the later stages of care (DX ¼ 27%, PRE ¼ 29%, SEL ¼ 27%, OPR ¼ 87%, and POC ¼ 84%). Residents completed the majority of each requirement more frequently in operations performed in the acute setting compared to elective operations: DX (70% vs 8%, p o 0.01), PRE (74% vs 10%, p o 0.01), SEL (65% vs 11%, p o 0.01), OPR (100% vs 89%, p ¼ 0.02), POC (100% vs 77%, p o 0.01). Resident participation was inversely related to operational complexity for DX (p o 0.01), PRE (p o 0.01), SEL (p o 0.01), and OPR (p ¼ 0.01). Resident involvement in OPR increased at the end of the academic year (p ¼ 0.05) and when working with junior attendings (o5 years in practice) (p ¼ 0.01). Interpair agreement was greatest for DX (rs ¼ 0.70) and lowest for POC (rs ¼ 0.35). When residents and attendings did not agree in their
Correspondence: Inquiries to Teviah Sachs, MD, MPH, Department of Surgical Oncology, Boston Medical Center, 820 Harrison Avenue, FGH Building, Suite 5007, Boston, MA 02118; fax: (617) 414-8012; e-mail: [email protected], [email protected]
Interpersonal and Communication Skills, Patient Care, and Practice Based Learning and Improvement
INTRODUCTION Historically, the training of general surgery residents has followed a Halstedian formula, with increasing autonomy commensurate with experience and ability. Although residency training has evolved with time, the tenets remain the same, with a focus on graduated responsibility both in and outside the operating room to develop the necessary independence and confidence upon graduation. More recently, however, a number of factors, including duty hour regulations, oversight, quality measures, and targeted goals for surgeon productivity have led to decreases in resident exposure to operative experiences and autonomy, both clinically and operatively.1-3 Although the overall number of cases a resident performs during training has not decreased, many residents have inadequate case volume in areas such as vascular, hepatopancreatobiliary, and pediatric surgery.4-6 It follows that this lack of experience may correlate with a loss
Journal of Surgical Education & 2016 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2016.10.012
1
of understanding of complex surgical operations and anatomy. Taken together, these factors have led to a training environment in which resident autonomy may suffer. The ACGME stipulates that general surgery residents must log a minimum of 750 cases as “surgeon” before graduation, and may only do so “when he or she can document a significant role” in each of the 5 core requirements: diagnosis, preoperative care, operation selection, operation, and postoperative care.7 The challenge, however, is that with limited autonomy and surgical rotations often condensed into 4-week blocks, it is unlikely that residents are able to consistently participate in all of these required aspects of care for a particular patient. We set out to better understand the resident role in the 5 ACGME core requirements and to further understand whether these constraints have affected residents’ perceptions of their roles in each of the above aspects of surgical care.
before June 24, 2015 were considered “Academic Year 2014-2015,” and surveys completed on or after June 24, 2015 were considered “Academic Year 2015-2016.” Responses were compared between groups and analyzed using SPSS (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). To analyze agreement between attending and resident responses, an aggregate level of agreement for each question was calculated using Spearman’s rank correlation coefficient (rs). We assessed how often attendings’ and residents’ responses were equivalent and, when discordant, how greatly they differed. For evaluation of resident involvement in each core requirement, the data of which were categorical, we used attending responses and employed Chi-square analysis seeking a significance level of p o 0.05.
RESULTS
We developed and employed a survey (Appendix A) that contains a series of questions relating to resident participation in each of the 5 aforementioned aspects of patient care required by the ACGME: diagnosis of the patient’s disease (DX), preoperative care of the patient (PRE), selection of the appropriate operation (SEL), performance of the operation (OPR), and postoperative care of the patient (POC). Survey questions were answered on a 5-point rating scale ranging from “Completely Attending” to “Completely Resident.” This survey project was conducted at a single tertiary academic medical institution in an urban environment. Paper surveys were placed in each of the hospital’s operating rooms and completed anonymously. General surgery residents (Residents) and attending surgeons (Attendings) were asked to complete surveys, separately, at the conclusion of each operation they performed in concert. Corresponding resident and attending surveys were paired after collection based upon the listed operating room and time of incision. All participants were educated on criteria for exclusion—the involvement of physician extenders, fellows, multiple attendings, or multiple residents. Surveys erroneously completed in operations that met these criteria were excluded. Certain characteristics of the respondents were gathered via the survey, including attending years in practice (YIP), resident postgraduate year (PGY), incision time, and title of operation performed. Attendings were subsequently categorized as junior attendings (YIP o 5) or senior attendings (YIP Z 5), while residents were categorized as junior residents (PGY 1-3) or senior residents (PGY 4-5). Operations were classified as low, moderate, or high complexity after careful analysis and consensus decision by independent surgeons. They were also classified as either acute or elective based on the operative setting. To assess the changes that occurred with the change in PGY, surveys completed
Over a 3-month period (May-July 2015), total 686 operations were performed at our institution; 387 surveys were collected from 226 operations, representing a response rate of at least 33%, although it was not possible to tabulate an exact number of operations that met inclusion criteria. Of the returned surveys, 85 (22%) met exclusion criteria although 302 (151 matched resident-attending pairs) were included for analysis. In the event that either a resident or attending did not record a response for a particular question, that pair was excluded from analysis of that particular ACGME core requirement. Of the attending surveys, 82 were completed by junior attendings and 67 by senior attendings. Of the resident surveys, 21 were completed by junior residents and 126 by senior residents. Respondent demographics and case characteristics were gathered (Table 1). Resident involvement was highest in the latter stages of care, with attendings crediting residents with completing at least 50% of the OPR and POC core requirements in 92% and 84% of surveys, respectively. Resident contributions reached a level of at least 50% less frequently in the DX (27%), PRE (29%), and SEL (27%) stages of care (Fig. 1). There was no significant difference for involvement of senior residents as compared to junior residents at any stage of care. However, residents working with junior attendings were more likely to complete at least half of OPR as compared to residents working with senior attendings (98% vs 85%, p o 0.01). Resident participation was higher as well for OPR in 2014 to 2015 (95% vs 86%, p ¼ 0.05) (Table 2). Resident participation decreased with increasing complexity of the operation for categories of DX (low complexity, 42%; moderate complexity, 17%; high complexity, 6%; p o 0.01), PRE (44%, 22%, 8%, p o 0.01), SEL (45%, 15%, 8%, p o 0.01), and OPR (99%, 85%, 86%, p ¼ 0.01). Residents involvement was higher in patients presenting for surgery in the acute setting for every
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Journal of Surgical Education Volume ]/Number ] ] 2016
METHODS
TABLE 1. Respondent Demographics and Case Characteristics Variable Attending surgeons General surgery residents
Operational complexity Operation acuity Region/specialty
Academic year
Subcategory
n
%
Junior (o5 years in practice) Senior (Z5 years in practice) Years in practice omitted PGY 1 PGY 2 PGY 3 PGY 4 PGY 5 PGY omitted Low complexity Moderate complexity High complexity Acute Elective Head and neck Thorax Upper GI Lower GI Skin and soft tissue Vascular/transplant Trauma/acute care Inguinal and umbilical hernia 2014-2015 2015-2016
82 67 2 10 0 11 36 90 4 74 41 36 46 105 26 4 46 15 26 4 8 22 102 49
54 44 1 7 0 7 24 60 3 49 27 24 30 70 17 3 30 10 17 3 5 15 68 32
core requirement when compared to elective operations: DX (70% vs 8%, p o 0.01), PRE (74% vs 10%, p o 0.01), SEL (65% vs 11%, p o 0.01), OPR (100% vs 89%, p ¼ 0.02), POC (100% vs 77%, p o 0.01). When analyzing level of agreement, resident survey responses correlated with those of attendings most frequently for DX (68%, rs ¼ 0.7, p o 0.01), followed by OPR (58%, rs ¼ 0.68, p o 0.01), PRE (56%, rs ¼ 0.64, p
o 0.01), SEL (53%, rs ¼ 0.64, p o 0.01), and POC (38%, rs ¼ 0.35, p o 0.01). Where attendings and residents disagreed, residents more frequently understated their involvement in OPR (57%) and POC (62%), while they more often overstated their involvement in DX (68%), PRE (58%), and SEL (64%) (Fig. 2). Neither resident group was more likely than the other to provide the same response as attendings on any question.
FIGURE 1. Responsibility for completion of each ACGME core requirement, as evaluated by attending surgeons. Journal of Surgical Education Volume ]/Number ] ] 2016
3
TABLE 2. Percentage of Cases in Which Residents Performed or Planned to Perform At Least 50% of Each ACGME Core Requirement Based on Resident Experience, Attending Surgeon Experience, Academic Year, Operational Acuity, and Operational Complexity
Junior GSR cases (n ¼ 21) Senior GSR cases (n ¼ 126) Junior AS cases (n ¼ 82) Senior AS cases (n ¼ 67) Academic year 2014-2015 (n ¼ n ¼ 102) Academic year 2015-2016 (n ¼ 49) Acute cases (n ¼ 46) Elective cases (n ¼ 105) Low complexity cases (n ¼ 74) Moderate complexity cases (n ¼ 41) High complexity cases (n ¼ 36)
Diagnosis (%)
Preoperative Care (%)
Operation Selection (%)
Operation (%)
Postoperative Care (%)
43 25 26 28 24
45 28 28 30 27
29 29 24 30 26
95 91 98* 85 95*
76 86 83 85 83
33
35
38
86
86
70* 8 42*
74* 10 44*
65* 11 45*
100* 89 99*
100* 77 85
17
22
15
85
80
6
8
8
86
86
*p o 0.05.
Residents were more likely to agree on the DX, however, when working with senior attendings (78% vs 60%, p ¼ 0.02). Agreement was higher as well for PRE (63% vs 42%, p ¼ 0.01) for residents in the end of their academic year (2014-2015 vs 2015-2016) (Table 3). Agreement increased with increasing operational complexity for DX (low complexity 54%, moderate complexity 85%, high complexity 79%, p o 0.01) and PRE (46%, 63%, 69%, p ¼ 0.04). Residents and attendings agreed significantly more often in the elective setting when compared to acute operations for DX (80% vs 42%, p o 0.01), PRE (66% vs 33%, p o 0.01), SEL (65% vs 27%, p o 0.01), and OPR (65% vs 43%, p ¼ 0.02).
FIGURE 2. Resident accuracy in self-assessment in each ACGME core requirement based on responses relative to attending surgeon responses (rs ¼ Spearman rank correlation).
development depends not only on a high surgical case volume but also on substantial and increasing longitudinal involvement in each case. In this study we found that resident participation in our program is weighted toward the operative and postoperative stages of care. Resident contributions to the preoperative and operative phases of care, on the cases in which they operated, decreased with increasing operational complexity, and participation in all stages increased in acute operations. For all stages except postoperative care, resident self-perceptions correlated well with attending surgeon evaluations. The incongruence in our data between involvement in the early and late stages of care suggests a lack of continuity for residents in surgical cases, which is corroborated by the literature.8,9 Both Turner et al.10 and Daly et al.11 have shown that none of the vascular and general surgery cases they respectively reviewed had complete resident-patient continuity. Turner et al. further concluded that this discontinuity, while likely related to abbreviated rotation lengths, was multifactorial, influenced by the method in which residents add cases and the lack of a proper system to alert residents that their patients have returned for postoperative care. Our study suggests similarly disjointed involvement by residents in elective operations. Interestingly, however, we show a significantly higher continuity of care maintained in acute care operations. This relationship of acuity of the operation, and of the patient, with resident involvement suggests a possible disconnect within our training of future surgeons. Patients whose disease process allows time for planning, discussion and education of residents seem to be the same cases where resident involvement is less uniform. Conversely, cases with a compressed time course of diagnostic and therapeutic intervention are those in which
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Journal of Surgical Education Volume ]/Number ] ] 2016
DISCUSSION The explicit end point of resident training is the ability to practice independently as a general surgeon. Resident
TABLE 3. Percentage of Cases in Which Residents and Attending Surgeons Provided the Same Response Regarding Resident Participation in Each ACGME Core Requirement Based on Resident Experience, Attending Surgeon Experience, Academic Year, Operational Acuity, and Operational Complexity
Junior GSR cases (n ¼ 21) Senior GSR cases (n ¼ 126) Junior AS cases (n ¼ 82) Senior AS cases (n¼67) Academic year 2014-2015 (n ¼ 102) Academic year 2015-2016 (n ¼ 49) Acute cases (n ¼ 46) Elective cases (n ¼ 105) Low complexity cases (n ¼ 74) Moderate complexity cases (n ¼ 41) High complexity cases (n ¼ 36)
Diagnosis (%)
Preoperative Care (%)
Operation Selection (%)
Operation (%)
Postoperative Care (%)
71* 68 60 78 73
55 57 56 56 63*
57 53 54 54 55
67 57 52 66 63
43 38 39 37 34
58
42
50
49
45
42 80* 54
33 66* 46
27 65* 47
43 65* 55
39 37 41
85*
63
53
56
37
79
69*
67
67
33
*p o 0.05.
residents are most involved and with greatest continuity. Rotation length plays a role in this divide as resident-patient continuity is invariably disrupted when there is a length of time between each stage of care. Residents at our institution spend, on average, only 8.7 weeks on each rotation, which drops to 8 weeks when vacations are taken into consideration. Rotations lengthen as residents progress, increasing in our program from a median of 4 weeks in the intern year, to a median of 10 weeks per rotation in the chief resident year. This indicates that continuity from clinic visit through the operation and the postoperative care may be especially difficult to maintain for junior residents. While seemingly short, these averages are comparable with similar academic programs across the country, suggesting that rotation schedules may affect resident involvement nationwide. This absence of continuity is not surprising given the current constraints within the system, but it is nonetheless concerning as training offers residents the opportunity for experience while still under supervision. Fortunately, there is evidence that overall resident case volume has remained stable or possibly increased since the implementation of the 2003 ACGME duty hour restrictions.12,13 Residents continue to struggle, however, in gaining appropriate exposure in specific areas of training. In 2006, Bell et al. identified 121 procedures that graduating residents should be able to perform independently, yet residents, on average, performed 31 of these operations less than once in their training.14 Separate studies have similarly concluded that graduating residents are not sufficiently exposed to more complex procedures in areas such as vascular, hepatopancreatobiliary, and pediatric surgery.4-6 There has also been a notable decrease in overall teaching assistant cases where residents can practice increased autonomy.13 Although we found that resident operative involvement in complex cases was high, few provided
preoperative care for these patients. Given the limited opportunities residents have to manage these cases with guidance, they would benefit from more longitudinal involvement. Encouragingly, residents in our study demonstrated accurate self-awareness of their role in care. The high interpair agreement we describe in every stage other than postoperative care suggests strong communication and coherence between residents and their attending surgeons. Moreover, the apparent lapse in agreement for postoperative care may be attributable to the fact that survey completion occurred immediately following each procedure, preceding postoperative planning. Several of the factors that led to decreased resident involvement, including increased operational complexity and the elective setting, were counterintuitively associated with higher agreement. A reasonable explanation for this ostensible contradiction is that lack of participation leaves less room for disagreement. Disagreement exists with significant participation, but efforts must be made to limit differences in perception. Having accurate self-perceptions plausibly allows residents to more fully capitalize on those opportunities where they do receive increased autonomy. Recent evidence, however, is divided as to whether residents agree with attending surgeons on their role. Kempenich et al.15 found that residents felt they deserved more autonomy in the operating room than attendings were willing to bestow. Meyerson et al.16 conversely found that resident and attending expectations for autonomy were comparable, yet also often went unrealized in practice. Establishing strong communication and ensuring that residents understand their role is a necessary first step toward building their independence. The current study has several limitations. Owing to the anonymity provided to survey respondents, it is not possible
Journal of Surgical Education Volume ]/Number ] ] 2016
5
to say how many attending surgeons and categorical residents participated in the project. Nor is it possible to quantify how many surveys each respondent completed. To protect confidentiality, no rotation-specific information was collected, making it unfeasible to specifically analyze how rotation length affects resident training. Despite the survey’s anonymity, it is also possible that respondents would have been hesitant to provide responses that they felt reflected poorly on themselves or their program. As surveys were completed immediately postoperatively, participants could only estimate resident participation in postoperative care. Resident responses were disproportionately weighted toward senior residents; this is likely because of the increased operative responsibilities of chief residents and the fact that many junior residents spend a significant portion of their time at participating, nonintegrated sites away from the sponsoring institution. Finally, our questionnaire was not pilot-tested in our department so as not to introduce bias before dissemination of the survey. However, we did validate our instrument by taking two steps. First, to establish content validity evidence, we aligned our items with those defined and vetted by the ACGME. Second, to obtain face validity evidence, we asked other surgeons to review our instrument items before they were administered and we made necessary revisions. The basis of fostering resident autonomy lies in the wellestablished volume-outcomes relationship for surgeons.17-19 Frustratingly, although patient outcomes are improved with surgeon experience, they decline with trainee involvement.20-23 Inferior outcomes and decreased productivity provide disincentives for attending surgeons to take the time to teach residents and thus increase autonomy.24-26 The
current study, fortunately, demonstrates that resident involvement in the operational stage is quite high in all settings, especially at the end of the academic year, suggesting gradual advancement as residents presumably improve their technical skills. This finding is reassuring given recent evidence that graduating residents may lack necessary confidence and ability.27,28 This lack of preparedness, with a concomitant rise in fellowship matriculation, suggests that residents’ transition to independence has become less likely to occur during residency.29,30 While we found residents’ operative experience to be adequate, the lack of prolonged patient continuity presented herein may indeed stunt more holistic development. This delayed maturation emphasizes the fundamental challenge we face in surgical training— efficiently, effectively, and responsibly bridging the gap in experience between trainee and surgeon. Exercising leadership in all stages of care allows residents to realistically simulate their future responsibilities beyond requisite technical skills. A gap remains between our expectations and the reality of resident training in surgery. Barriers exist to the continuity of care that we endeavor for our residents, particularly in higher complexity, elective operations. Future goals focus on devising and employing improved models of training to better the experience of general surgery residents.
APPENDIX A See Table A1 for postoperative case survey completed by residents and attending surgeons.
TABLE A1. Postoperative Case Survey Completed by Residents and Attending Surgeons Postoperative Survey Instructions: This is a research study that examines how Residents and Attending physicians view their involvement with specific surgical procedures. This survey should take you no more than 5-10 min, participation is voluntary and if you do not wish to participate it will not affect your professional or personal standing in any way. Further, your participation will remain confidential and you are free to choose not to answer any questions you do not wish to answer. There is no compensation for your participation. Thank you for your participation. Date of operation: __________________ Incision time: _______________________ Operation performed: _____________________________________________________ Please circle your role: Attending/ resident If attending, years in practice: o5 5-10 410 If resident, current year of residency: 1 2 3 4 5 Questions Completely Mostly About Mostly Completely attending attending 50/50 resident resident (1) Who was involved in determining the diagnosis for 1 2 3 4 5 this patient? (2) Who provided preoperative care for this patient? 1 2 3 4 5 (3) Who selected the appropriate operation for this 1 2 3 4 5 patient? (4) Who conducted the operation for this patient? 1 2 3 4 5 (5) Who do you believe will direct the postoperative 1 2 3 4 5 care for this patient?
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13. Sachs TE, Pawlik TM. See one, do one, and teach
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DaRosa D, Joehl RJ. And doctor, no residents please!. J Am Coll Surg. 2003;197:1012-1017. 2. Pellegrini CA, Warshaw AL, Debas HT. Residency
training in surgery in the 21st century: a new paradigm. Surgery. 2004;136:953-965. 3. Dudrick SJ. Overview of Gerneral Surgery Training in
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graduating surgical residents confident in performing open vascular surgery? Results of a national survey J Surg Educ. 2015. 5. Talutis S, McAneny D, Chen C, Doherty G, Sachs T.
Trends in pediatric surgery operative volume among residents and fellows: improving the experience for all. J Am Coll Surg. 2015. 6. Sachs TE, Ejaz A, Weiss M, et al. Assessing the
experience in complex hepatopancreatobiliary surgery among graduating chief residents: is the operative experience enough? Surgery. 2014;156:385-393. 7. ACGME Program Requirements for Graduate Medical
Education in General Surgery. 2016: Accreditation Council for Graduate Medical Education; 2011. 8. Antiel RM, Reed DA, Van Arendonk KJ, et al. Effects
of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. JAMA Surg. 2013;148:448-455. 9. Desai SV, Feldman L, Brown L, et al. Effect of the
2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial. JAMA Intern Med. 2013;173: 649-655. 10. Turner JP, Rodriguez HE, Daskin MS, Mehrotra S,
Speicher P, DaRosa DA. Overcoming obstacles to resident-patient continuity of care. Ann Surg. 2012;255:618-622. 11. Daly SC, Klairmont MM, Rinewalt D, Luu MB,
Myers JA. Continuity of care in general surgery resident education. Am J Surg. 2015;210: 175-178. 12. Malangoni MA, Biester TW, Jones AT, Klingensmith ME, Lewis FR Jr. Operative experience of surgery residents: trends and challenges. J Surg Educ. 2013;70: 783-788.
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none: resident experience as a teaching assistant. J Surg Res. 2015;195:44-51. 14. Bell RH Jr., Biester TW, Tabuenca A, et al. Operative
experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg. 2009;249:719-724. 15. Kempenich JW, Willis RE, Rakosi R, Wiersch J,
Schenarts PJ. How do perceptions of autonomy differ in general surgery training between faculty, senior residents, hospital administrators, and the general public? A multi-institutional study J Surg Educ. 2015;72:e193-201. 16. Meyerson SL, Teitelbaum EN, George BC, Schuller
MC, DaRosa DA, Fryer JP. Defining the autonomy gap: when expectations do not meet reality in the operating room. J Surg Educ. 2014;71:e64-72. 17. Begg CB, Cramer LD, Hoskins WJ, Brennan MF.
Impact of hospital volume on operative mortality for major cancer surgery. J Am Med Assoc. 1998;280: 1747-1751. 18. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP,
Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349:2117-2127. 19. McPhee JT, Robinson WP 3rd, Eslami MH, Arous
EJ, Messina LM, Schanzer A. Surgeon case volume, not institution case volume, is the primary determinant of in-hospital mortality after elective open abdominal aortic aneurysm repair. J Vasc Surg. 2011; 53:591-599 e592. 20. Iannuzzi JC, Chandra A, Rickles AS, et al. Resident
involvement is associated with worse outcomes after major lower extremity amputation. J Vasc Surg. 2013; 58:827-831 e821. 21. Glance LG, Mukamel DB, Blumberg N, Fleming FJ,
Hohmann SF, Dick AW. Association between surgical resident involvement and blood use in noncardiac surgery. Transfusion. 2014;54:691-700. 22. DiDato S, Farber A, Rybin D, et al. The effect of
trainee involvement on perioperative outcomes of abdominal aortic aneurysm repair. J Vasc Surg. 2016; 63:16-22. 23. Kasotakis G, Lakha A, Sarkar B, et al. Trainee
participation is associated with adverse outcomes in emergency general surgery: an analysis of the National Surgical Quality Improvement Program database. Ann Surg. 2014;260:483-490; discussion 490-483.
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trainee impact on operative time for common general surgical procedures in ACS-NSQIP. J Surg Educ. 2012;69: 149-155. 27. Fonseca AL, Reddy V, Longo WE, Gusberg RJ.
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Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery. J Am Coll Surg. 2008;206:782-788; discussion 788-789.
Journal of Surgical Education Volume ]/Number ] ] 2016
Resident and Attending Perceptions of Resident Involvement: An Analysis of ACGME Reporting Guidelines Ryan Morgan, BS, Douglas F. Kauffman, PhD, Gerard Doherty, MD and Teviah Sachs, MD, MPH Department of Surgery, Boston University School of Medicine, Boston, Massachusetts OBJECTIVE: For general surgery residents (Residents) to log an operation, the ACGME requires “significant involvement” in diagnosis (DX), operation selection (SEL), operation (OPR), preoperative (PRE), and postoperative (POC) care. We compared how residents and attending surgeons (Attendings) perceived residents’ role in each of these core requirements.
answers, residents generally overstated their contribution to the DX (68%), PRE (58%), and SEL (64%) but understated their contribution in OPR (63%) and POC (62%).
postoperatively regarding responsibility for each core requirement on a 5-point Likert scale from “Completely Attending” to “Completely Resident.” Significance was determined using Chi-square analysis (p o 0.05) and degree of agreement was calculated using Spearman’s rank correlation (rs).
CONCLUSIONS: Residents and attendings demonstrated reliable agreement for most core requirements, but residents were often unable to be involved in all 5 core requirements. Resident involvement was weighted toward later stages of patient care, yet residents often underestimated their contributions. Operational acuity, complexity, and attending experience correlated with resident operative involvement. C 2016 Association of Program ( J Surg Ed ]:]]]-]]]. J Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
SETTING: Boston Medical Center, Boston, MA (tertiary
KEY WORDS: resident education, surgical training, resi-
institution).
dent perception, case log, ACGME, attending agreement
RESULTS: A total of 302 paired surveys were analyzed.
COMPETENCIES:
DESIGN: Residents and attendings completed surveys
Residents more often performed a significant portion of the later stages of care (DX ¼ 27%, PRE ¼ 29%, SEL ¼ 27%, OPR ¼ 87%, and POC ¼ 84%). Residents completed the majority of each requirement more frequently in operations performed in the acute setting compared to elective operations: DX (70% vs 8%, p o 0.01), PRE (74% vs 10%, p o 0.01), SEL (65% vs 11%, p o 0.01), OPR (100% vs 89%, p ¼ 0.02), POC (100% vs 77%, p o 0.01). Resident participation was inversely related to operational complexity for DX (p o 0.01), PRE (p o 0.01), SEL (p o 0.01), and OPR (p ¼ 0.01). Resident involvement in OPR increased at the end of the academic year (p ¼ 0.05) and when working with junior attendings (o5 years in practice) (p ¼ 0.01). Interpair agreement was greatest for DX (rs ¼ 0.70) and lowest for POC (rs ¼ 0.35). When residents and attendings did not agree in their
Correspondence: Inquiries to Teviah Sachs, MD, MPH, Department of Surgical Oncology, Boston Medical Center, 820 Harrison Avenue, FGH Building, Suite 5007, Boston, MA 02118; fax: (617) 414-8012; e-mail: [email protected], [email protected]
Interpersonal and Communication Skills, Patient Care, and Practice Based Learning and Improvement
INTRODUCTION Historically, the training of general surgery residents has followed a Halstedian formula, with increasing autonomy commensurate with experience and ability. Although residency training has evolved with time, the tenets remain the same, with a focus on graduated responsibility both in and outside the operating room to develop the necessary independence and confidence upon graduation. More recently, however, a number of factors, including duty hour regulations, oversight, quality measures, and targeted goals for surgeon productivity have led to decreases in resident exposure to operative experiences and autonomy, both clinically and operatively.1-3 Although the overall number of cases a resident performs during training has not decreased, many residents have inadequate case volume in areas such as vascular, hepatopancreatobiliary, and pediatric surgery.4-6 It follows that this lack of experience may correlate with a loss
Journal of Surgical Education & 2016 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2016.10.012
1
of understanding of complex surgical operations and anatomy. Taken together, these factors have led to a training environment in which resident autonomy may suffer. The ACGME stipulates that general surgery residents must log a minimum of 750 cases as “surgeon” before graduation, and may only do so “when he or she can document a significant role” in each of the 5 core requirements: diagnosis, preoperative care, operation selection, operation, and postoperative care.7 The challenge, however, is that with limited autonomy and surgical rotations often condensed into 4-week blocks, it is unlikely that residents are able to consistently participate in all of these required aspects of care for a particular patient. We set out to better understand the resident role in the 5 ACGME core requirements and to further understand whether these constraints have affected residents’ perceptions of their roles in each of the above aspects of surgical care.
before June 24, 2015 were considered “Academic Year 2014-2015,” and surveys completed on or after June 24, 2015 were considered “Academic Year 2015-2016.” Responses were compared between groups and analyzed using SPSS (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). To analyze agreement between attending and resident responses, an aggregate level of agreement for each question was calculated using Spearman’s rank correlation coefficient (rs). We assessed how often attendings’ and residents’ responses were equivalent and, when discordant, how greatly they differed. For evaluation of resident involvement in each core requirement, the data of which were categorical, we used attending responses and employed Chi-square analysis seeking a significance level of p o 0.05.
RESULTS
We developed and employed a survey (Appendix A) that contains a series of questions relating to resident participation in each of the 5 aforementioned aspects of patient care required by the ACGME: diagnosis of the patient’s disease (DX), preoperative care of the patient (PRE), selection of the appropriate operation (SEL), performance of the operation (OPR), and postoperative care of the patient (POC). Survey questions were answered on a 5-point rating scale ranging from “Completely Attending” to “Completely Resident.” This survey project was conducted at a single tertiary academic medical institution in an urban environment. Paper surveys were placed in each of the hospital’s operating rooms and completed anonymously. General surgery residents (Residents) and attending surgeons (Attendings) were asked to complete surveys, separately, at the conclusion of each operation they performed in concert. Corresponding resident and attending surveys were paired after collection based upon the listed operating room and time of incision. All participants were educated on criteria for exclusion—the involvement of physician extenders, fellows, multiple attendings, or multiple residents. Surveys erroneously completed in operations that met these criteria were excluded. Certain characteristics of the respondents were gathered via the survey, including attending years in practice (YIP), resident postgraduate year (PGY), incision time, and title of operation performed. Attendings were subsequently categorized as junior attendings (YIP o 5) or senior attendings (YIP Z 5), while residents were categorized as junior residents (PGY 1-3) or senior residents (PGY 4-5). Operations were classified as low, moderate, or high complexity after careful analysis and consensus decision by independent surgeons. They were also classified as either acute or elective based on the operative setting. To assess the changes that occurred with the change in PGY, surveys completed
Over a 3-month period (May-July 2015), total 686 operations were performed at our institution; 387 surveys were collected from 226 operations, representing a response rate of at least 33%, although it was not possible to tabulate an exact number of operations that met inclusion criteria. Of the returned surveys, 85 (22%) met exclusion criteria although 302 (151 matched resident-attending pairs) were included for analysis. In the event that either a resident or attending did not record a response for a particular question, that pair was excluded from analysis of that particular ACGME core requirement. Of the attending surveys, 82 were completed by junior attendings and 67 by senior attendings. Of the resident surveys, 21 were completed by junior residents and 126 by senior residents. Respondent demographics and case characteristics were gathered (Table 1). Resident involvement was highest in the latter stages of care, with attendings crediting residents with completing at least 50% of the OPR and POC core requirements in 92% and 84% of surveys, respectively. Resident contributions reached a level of at least 50% less frequently in the DX (27%), PRE (29%), and SEL (27%) stages of care (Fig. 1). There was no significant difference for involvement of senior residents as compared to junior residents at any stage of care. However, residents working with junior attendings were more likely to complete at least half of OPR as compared to residents working with senior attendings (98% vs 85%, p o 0.01). Resident participation was higher as well for OPR in 2014 to 2015 (95% vs 86%, p ¼ 0.05) (Table 2). Resident participation decreased with increasing complexity of the operation for categories of DX (low complexity, 42%; moderate complexity, 17%; high complexity, 6%; p o 0.01), PRE (44%, 22%, 8%, p o 0.01), SEL (45%, 15%, 8%, p o 0.01), and OPR (99%, 85%, 86%, p ¼ 0.01). Residents involvement was higher in patients presenting for surgery in the acute setting for every
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METHODS
TABLE 1. Respondent Demographics and Case Characteristics Variable Attending surgeons General surgery residents
Operational complexity Operation acuity Region/specialty
Academic year
Subcategory
n
%
Junior (o5 years in practice) Senior (Z5 years in practice) Years in practice omitted PGY 1 PGY 2 PGY 3 PGY 4 PGY 5 PGY omitted Low complexity Moderate complexity High complexity Acute Elective Head and neck Thorax Upper GI Lower GI Skin and soft tissue Vascular/transplant Trauma/acute care Inguinal and umbilical hernia 2014-2015 2015-2016
82 67 2 10 0 11 36 90 4 74 41 36 46 105 26 4 46 15 26 4 8 22 102 49
54 44 1 7 0 7 24 60 3 49 27 24 30 70 17 3 30 10 17 3 5 15 68 32
core requirement when compared to elective operations: DX (70% vs 8%, p o 0.01), PRE (74% vs 10%, p o 0.01), SEL (65% vs 11%, p o 0.01), OPR (100% vs 89%, p ¼ 0.02), POC (100% vs 77%, p o 0.01). When analyzing level of agreement, resident survey responses correlated with those of attendings most frequently for DX (68%, rs ¼ 0.7, p o 0.01), followed by OPR (58%, rs ¼ 0.68, p o 0.01), PRE (56%, rs ¼ 0.64, p
o 0.01), SEL (53%, rs ¼ 0.64, p o 0.01), and POC (38%, rs ¼ 0.35, p o 0.01). Where attendings and residents disagreed, residents more frequently understated their involvement in OPR (57%) and POC (62%), while they more often overstated their involvement in DX (68%), PRE (58%), and SEL (64%) (Fig. 2). Neither resident group was more likely than the other to provide the same response as attendings on any question.
FIGURE 1. Responsibility for completion of each ACGME core requirement, as evaluated by attending surgeons. Journal of Surgical Education Volume ]/Number ] ] 2016
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TABLE 2. Percentage of Cases in Which Residents Performed or Planned to Perform At Least 50% of Each ACGME Core Requirement Based on Resident Experience, Attending Surgeon Experience, Academic Year, Operational Acuity, and Operational Complexity
Junior GSR cases (n ¼ 21) Senior GSR cases (n ¼ 126) Junior AS cases (n ¼ 82) Senior AS cases (n ¼ 67) Academic year 2014-2015 (n ¼ n ¼ 102) Academic year 2015-2016 (n ¼ 49) Acute cases (n ¼ 46) Elective cases (n ¼ 105) Low complexity cases (n ¼ 74) Moderate complexity cases (n ¼ 41) High complexity cases (n ¼ 36)
Diagnosis (%)
Preoperative Care (%)
Operation Selection (%)
Operation (%)
Postoperative Care (%)
43 25 26 28 24
45 28 28 30 27
29 29 24 30 26
95 91 98* 85 95*
76 86 83 85 83
33
35
38
86
86
70* 8 42*
74* 10 44*
65* 11 45*
100* 89 99*
100* 77 85
17
22
15
85
80
6
8
8
86
86
*p o 0.05.
Residents were more likely to agree on the DX, however, when working with senior attendings (78% vs 60%, p ¼ 0.02). Agreement was higher as well for PRE (63% vs 42%, p ¼ 0.01) for residents in the end of their academic year (2014-2015 vs 2015-2016) (Table 3). Agreement increased with increasing operational complexity for DX (low complexity 54%, moderate complexity 85%, high complexity 79%, p o 0.01) and PRE (46%, 63%, 69%, p ¼ 0.04). Residents and attendings agreed significantly more often in the elective setting when compared to acute operations for DX (80% vs 42%, p o 0.01), PRE (66% vs 33%, p o 0.01), SEL (65% vs 27%, p o 0.01), and OPR (65% vs 43%, p ¼ 0.02).
FIGURE 2. Resident accuracy in self-assessment in each ACGME core requirement based on responses relative to attending surgeon responses (rs ¼ Spearman rank correlation).
development depends not only on a high surgical case volume but also on substantial and increasing longitudinal involvement in each case. In this study we found that resident participation in our program is weighted toward the operative and postoperative stages of care. Resident contributions to the preoperative and operative phases of care, on the cases in which they operated, decreased with increasing operational complexity, and participation in all stages increased in acute operations. For all stages except postoperative care, resident self-perceptions correlated well with attending surgeon evaluations. The incongruence in our data between involvement in the early and late stages of care suggests a lack of continuity for residents in surgical cases, which is corroborated by the literature.8,9 Both Turner et al.10 and Daly et al.11 have shown that none of the vascular and general surgery cases they respectively reviewed had complete resident-patient continuity. Turner et al. further concluded that this discontinuity, while likely related to abbreviated rotation lengths, was multifactorial, influenced by the method in which residents add cases and the lack of a proper system to alert residents that their patients have returned for postoperative care. Our study suggests similarly disjointed involvement by residents in elective operations. Interestingly, however, we show a significantly higher continuity of care maintained in acute care operations. This relationship of acuity of the operation, and of the patient, with resident involvement suggests a possible disconnect within our training of future surgeons. Patients whose disease process allows time for planning, discussion and education of residents seem to be the same cases where resident involvement is less uniform. Conversely, cases with a compressed time course of diagnostic and therapeutic intervention are those in which
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DISCUSSION The explicit end point of resident training is the ability to practice independently as a general surgeon. Resident
TABLE 3. Percentage of Cases in Which Residents and Attending Surgeons Provided the Same Response Regarding Resident Participation in Each ACGME Core Requirement Based on Resident Experience, Attending Surgeon Experience, Academic Year, Operational Acuity, and Operational Complexity
Junior GSR cases (n ¼ 21) Senior GSR cases (n ¼ 126) Junior AS cases (n ¼ 82) Senior AS cases (n¼67) Academic year 2014-2015 (n ¼ 102) Academic year 2015-2016 (n ¼ 49) Acute cases (n ¼ 46) Elective cases (n ¼ 105) Low complexity cases (n ¼ 74) Moderate complexity cases (n ¼ 41) High complexity cases (n ¼ 36)
Diagnosis (%)
Preoperative Care (%)
Operation Selection (%)
Operation (%)
Postoperative Care (%)
71* 68 60 78 73
55 57 56 56 63*
57 53 54 54 55
67 57 52 66 63
43 38 39 37 34
58
42
50
49
45
42 80* 54
33 66* 46
27 65* 47
43 65* 55
39 37 41
85*
63
53
56
37
79
69*
67
67
33
*p o 0.05.
residents are most involved and with greatest continuity. Rotation length plays a role in this divide as resident-patient continuity is invariably disrupted when there is a length of time between each stage of care. Residents at our institution spend, on average, only 8.7 weeks on each rotation, which drops to 8 weeks when vacations are taken into consideration. Rotations lengthen as residents progress, increasing in our program from a median of 4 weeks in the intern year, to a median of 10 weeks per rotation in the chief resident year. This indicates that continuity from clinic visit through the operation and the postoperative care may be especially difficult to maintain for junior residents. While seemingly short, these averages are comparable with similar academic programs across the country, suggesting that rotation schedules may affect resident involvement nationwide. This absence of continuity is not surprising given the current constraints within the system, but it is nonetheless concerning as training offers residents the opportunity for experience while still under supervision. Fortunately, there is evidence that overall resident case volume has remained stable or possibly increased since the implementation of the 2003 ACGME duty hour restrictions.12,13 Residents continue to struggle, however, in gaining appropriate exposure in specific areas of training. In 2006, Bell et al. identified 121 procedures that graduating residents should be able to perform independently, yet residents, on average, performed 31 of these operations less than once in their training.14 Separate studies have similarly concluded that graduating residents are not sufficiently exposed to more complex procedures in areas such as vascular, hepatopancreatobiliary, and pediatric surgery.4-6 There has also been a notable decrease in overall teaching assistant cases where residents can practice increased autonomy.13 Although we found that resident operative involvement in complex cases was high, few provided
preoperative care for these patients. Given the limited opportunities residents have to manage these cases with guidance, they would benefit from more longitudinal involvement. Encouragingly, residents in our study demonstrated accurate self-awareness of their role in care. The high interpair agreement we describe in every stage other than postoperative care suggests strong communication and coherence between residents and their attending surgeons. Moreover, the apparent lapse in agreement for postoperative care may be attributable to the fact that survey completion occurred immediately following each procedure, preceding postoperative planning. Several of the factors that led to decreased resident involvement, including increased operational complexity and the elective setting, were counterintuitively associated with higher agreement. A reasonable explanation for this ostensible contradiction is that lack of participation leaves less room for disagreement. Disagreement exists with significant participation, but efforts must be made to limit differences in perception. Having accurate self-perceptions plausibly allows residents to more fully capitalize on those opportunities where they do receive increased autonomy. Recent evidence, however, is divided as to whether residents agree with attending surgeons on their role. Kempenich et al.15 found that residents felt they deserved more autonomy in the operating room than attendings were willing to bestow. Meyerson et al.16 conversely found that resident and attending expectations for autonomy were comparable, yet also often went unrealized in practice. Establishing strong communication and ensuring that residents understand their role is a necessary first step toward building their independence. The current study has several limitations. Owing to the anonymity provided to survey respondents, it is not possible
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to say how many attending surgeons and categorical residents participated in the project. Nor is it possible to quantify how many surveys each respondent completed. To protect confidentiality, no rotation-specific information was collected, making it unfeasible to specifically analyze how rotation length affects resident training. Despite the survey’s anonymity, it is also possible that respondents would have been hesitant to provide responses that they felt reflected poorly on themselves or their program. As surveys were completed immediately postoperatively, participants could only estimate resident participation in postoperative care. Resident responses were disproportionately weighted toward senior residents; this is likely because of the increased operative responsibilities of chief residents and the fact that many junior residents spend a significant portion of their time at participating, nonintegrated sites away from the sponsoring institution. Finally, our questionnaire was not pilot-tested in our department so as not to introduce bias before dissemination of the survey. However, we did validate our instrument by taking two steps. First, to establish content validity evidence, we aligned our items with those defined and vetted by the ACGME. Second, to obtain face validity evidence, we asked other surgeons to review our instrument items before they were administered and we made necessary revisions. The basis of fostering resident autonomy lies in the wellestablished volume-outcomes relationship for surgeons.17-19 Frustratingly, although patient outcomes are improved with surgeon experience, they decline with trainee involvement.20-23 Inferior outcomes and decreased productivity provide disincentives for attending surgeons to take the time to teach residents and thus increase autonomy.24-26 The
current study, fortunately, demonstrates that resident involvement in the operational stage is quite high in all settings, especially at the end of the academic year, suggesting gradual advancement as residents presumably improve their technical skills. This finding is reassuring given recent evidence that graduating residents may lack necessary confidence and ability.27,28 This lack of preparedness, with a concomitant rise in fellowship matriculation, suggests that residents’ transition to independence has become less likely to occur during residency.29,30 While we found residents’ operative experience to be adequate, the lack of prolonged patient continuity presented herein may indeed stunt more holistic development. This delayed maturation emphasizes the fundamental challenge we face in surgical training— efficiently, effectively, and responsibly bridging the gap in experience between trainee and surgeon. Exercising leadership in all stages of care allows residents to realistically simulate their future responsibilities beyond requisite technical skills. A gap remains between our expectations and the reality of resident training in surgery. Barriers exist to the continuity of care that we endeavor for our residents, particularly in higher complexity, elective operations. Future goals focus on devising and employing improved models of training to better the experience of general surgery residents.
APPENDIX A See Table A1 for postoperative case survey completed by residents and attending surgeons.
TABLE A1. Postoperative Case Survey Completed by Residents and Attending Surgeons Postoperative Survey Instructions: This is a research study that examines how Residents and Attending physicians view their involvement with specific surgical procedures. This survey should take you no more than 5-10 min, participation is voluntary and if you do not wish to participate it will not affect your professional or personal standing in any way. Further, your participation will remain confidential and you are free to choose not to answer any questions you do not wish to answer. There is no compensation for your participation. Thank you for your participation. Date of operation: __________________ Incision time: _______________________ Operation performed: _____________________________________________________ Please circle your role: Attending/ resident If attending, years in practice: o5 5-10 410 If resident, current year of residency: 1 2 3 4 5 Questions Completely Mostly About Mostly Completely attending attending 50/50 resident resident (1) Who was involved in determining the diagnosis for 1 2 3 4 5 this patient? (2) Who provided preoperative care for this patient? 1 2 3 4 5 (3) Who selected the appropriate operation for this 1 2 3 4 5 patient? (4) Who conducted the operation for this patient? 1 2 3 4 5 (5) Who do you believe will direct the postoperative 1 2 3 4 5 care for this patient?
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13. Sachs TE, Pawlik TM. See one, do one, and teach
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