- Email: [email protected]
Residents’ Experience in Breast Cancer Care
ORIGINAL REPORTS
Residents’ Experience in Breast Cancer Care$ R. Gregory Conway, MD, Edmund K. Bartlett, MD, Rebecca L. Hoffman, MD, Brian J. Czerniecki, MD, PhD, Giorgos C. Karakousis, MD, FACS and Rachel R. Kelz, MD, MSCE, FACS Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania OBJECTIVE: General surgeons commonly treat breast cancer (BC), hence necessitating adequate training during residency. We examined surgery residents’ exposure to these conditions across postgraduate years (PGYs) to assess the proximity of involvement to commencement.
KEY WORDS: breast cancer, NSQIP, oncology, resident,
SCORE COMPETENCIES: Patient Care, Medical Knowledge, Practice-Based Learning
STUDY DESIGN: We examined the BC operative profile
by PGY using the American College of Surgeons National Surgical Quality Improvement Program Participant Use File (ACS NSQIP PUF, 2008-2011). Operations were classified using the Surgical Council on Resident Education curriculum complexity categories. Univariate analysis was performed using chi-square, Fisher exact, analysis of variance, and Kruskal-Wallis tests, as appropriate. RESULTS: Of 58,413 BC operations, 23,996 involved PGY1 to PGY5 residents. A Surgical Council on Resident Education complexity was assigned to 97.7% of operations studied (n ¼ 23,432). PGY was inversely proportional to the number of operations performed. PGY1 to PGY3 residents covered most essential-common operations (PGY1-3, 72% vs PGY4-5, 28%; p o 0.001). PGY1 and PGY2 residents covered more than half of the complex operations (PGY1-2, 55% [n ¼ 359] vs PGY3-5, 45% [n ¼ 288]; p ¼ 0.033). CONCLUSIONS: Although junior residents perform most
of the BC cases in surgical residency, residents do participate in operations for BC across the continuum of the training years. Program directors should consider trainees’ career aspirations to ensure adequate exposure to the operative and nonoperative management of this common disease before C the transition to independent practice. ( J Surg ]:]]]-]]]. J 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) ☆ The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein. The Accreditation Council for Graduate Medical Education—General Surgery Case Log data were used for analysis in this study. The analysis and interpretation of the results is the sole responsibility of the authors. The data providers are not responsible for any statistical validity of the data analysis or the conclusions derived by the authors. Correspondence: Inquiries to Rachel R. Kelz, MD, MSCE, FACS, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA 19104; fax: (215) 662-7476; e-mail: [email protected]
INTRODUCTION Breast cancer has an incidence rate of 121.9 per 100,000 people, making the disease the most common cancer in women in the United States.1 Surgery is the mainstay of curative therapy for this disease. Surgeon volume and specialty training are associated with both short- and longterm oncologic outcomes.2-7 Despite the known association between fellowship training and cancer care, general surgeons perform a substantial proportion of breast cancer surgery.8 Technically, this approach is reasonable because the operations, for the most part, can be performed using techniques learned during general surgery residency. Furthermore, as there exists a shortage and maldistribution of surgeons, specialty training is not practical when considering the needs of the population as a whole.9,10 However, breast cancer treatment requires a multidisciplinary approach coupled with up-to-date knowledge of best practice guidelines to achieve optimal patient outcomes.11 Therefore, exposure during the general surgery residency must provide training that would be valuable at the time of the transition to practice in order to benefit the patients treated by these surgeons. Surgical education has a long tradition of introducing residents first to common essential operations, followed by a focus on more technically demanding complex operations. This approach is necessary to permit a graduated level of responsibility and autonomy without the unnecessary exposure of patients to risk. More recently, it has been recognized that the types of procedures and diseases seen during residency are not always representative of the types of procedures performed and diseases treated by practicing general surgeons.12 Frequently, for diseases such as breast cancer, the technical complexity of the operation is unrelated to the
Journal of Surgical Education & 2015 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.2015.04.028
1
cognitive complexity of the patient management. As surgical exposure is often centered on operative complexity, senior surgical residents may not receive adequate exposure immediately before graduation. Therefore, we sought to examine the exposure of general surgery residents to breast cancer operations by postgraduate year (PGY) of training to understand the proximity of their experience to their transition to practice.
MATERIAL AND METHODS Data source We identified patients recorded in the American College of Surgeons National Surgical Quality Improvement Program Participant Use File (ACS NSQIP PUF, fiscal year: 20082011) with a postoperative diagnosis of breast cancer using the International Classification of Diseases Ninth Revision diagnosis codes (174, 174.0-174.6, 174.8, 174.9, 175, 175.0, and 175.9). Patients were included in the study if they underwent an operation for the treatment of breast cancer using the Current Procedural Terminology (CPT) codes (Table 1) and a PGY1 to PGY5 level resident participated in the operation. Resident level was assigned using the PGY in training of the resident as recorded in the ACS NSQIP database. The ACS NSQIP PUF contains data on 252 variables, including preoperative risk factors, intraoperative variables, and morbidity and mortality outcomes in both the inpatient and the outpatient settings. The 2011 sample, for example, contains data on 442,149 cases from 315 participating sites. The sampling procedure selects completed cases from hospital operative logs on an 8-day cycle. This method captures data for the first 40 consecutive cases meeting the inclusion/exclusion criteria for the cycle for high-volume hospitals. For low-volume hospitals, all cases meeting the inclusion/exclusion criteria are collected.13 Data collection
Essential-common Axillary lymphadenectomy Axillary SLNB Breast biopsy with or without needle localization Duct excision Lymph node biopsy Mastectomy—modified radical Mastectomy—partial Mastectomy—simple Essential-uncommon Mastectomy—radical Complex Breast biopsy—image guided 2
Procedures were classified using the Surgical Council on Resident Education (SCORE) complexity categories. The SCORE curriculum was created in an effort to standardize surgical resident training,12,15,16 and it not only classifies procedural competencies based on technical complexity but also provides a framework for resident knowledge. The CPT codes recorded for each case were mapped to educational topics defined by the SCORE curriculum. Complexity values were assigned to each case based on the most complex procedure performed by the primary surgical team. Procedures that did not align with these categories were assigned a complexity of “other.” The assignment of a CPT code to a SCORE topic is shown in Table 1. The SCORE curriculum defines 3 complexity categories17: 1. Essential-common: Frequently performed operations in general surgery; specific procedure competency is required by end of training. 2. Essential-uncommon: Uncommon, often urgent, operations seen in general surgery practice and not typically done in significant numbers by residents; specific procedure competency required by the end of training (but cannot be attained by case volume alone). 3. Complex: Not consistently performed by general surgeons in training and not typically performed in general surgery practice. Generic experience in complex procedures is required but not competence in individual procedures. Some residency programs may provide sufficient experience for competence in some specific procedures.
19112, 19120 38510, 38520 19302 19303, 19304
Statistical Analysis
CPT Codes 38525, 38740, 38745 38792, 38900 19101, 19125 19110, 38500, 19307 19301, 19300,
Variable Definitions
Patient variables of interest included age, gender, the American Society of Anesthesiology Physical Status Classification (ASA class), estimated probability of morbidity and mortality, body mass index, and elderly status (65 years and older). Operative variables examined included inpatient/ outpatient status, level of resident supervision (presence of an attending physician), total operation time, emergency case, and previous operation within 30 days. Oncologic variables of interest include chemotherapy within 30 days of the operation, radiation therapy within 90 days, and the presence of disseminated cancer.
TABLE 1. Assignment of SCORE Topic and SCORE Complexity to CPT Codes SCORE Complexity SCORE patient care topic
personnel who populate the ACS NSQIP database undergo thorough training, and internal audit procedures have been found to be highly effective in ensuring data reliability.14
19305, 19306 19290, 19291, 19295
Descriptive statistics were examined. Univariate analyses were performed using chi-square or Fisher exact tests for categorical variables and analysis of variance or KruskalJournal of Surgical Education Volume ]/Number ] ] 2015
Wallis tests for continuous variables, as appropriate. To evaluate whether there was a significant trend in proportion of case participation by PGY, a nonparametric trend test for the analysis of proportions was performed. A p o 0.05 was considered statistically significant. Statistical analysis was performed using Stata 12.0/IC statistical software (StataCorp, College Station, TX).18 This study was approved by the University of Pennsylvania’s Institutional Review Board and deemed exempt from continuing review. In an effort to evaluate our results in the context of the national experience with breast surgery by PGY, we also analyzed the Accreditation Council for Graduate Medical Education (ACGME) General Surgery Case Log (GSCL) data for breast surgeries.19 The ACGME GSCL data set is the centralized repository of resident operative experience across all ACGME-accredited general surgery residency programs. Residents are expected to log all operations in which they participated over the 5 years of their surgical residency. Procedures are categorized based on the resident review committee subject area, and we identified surgeries categorized as breast related. The number of operations are tabulated by the surgeon chief, the surgeon junior, and overall. Percentages were calculated from these tables.
RESULTS We identified 58,413 patients with breast cancer. Patients were excluded from the study for missing information on surgical specialty (n ¼ 116) or missing PGY information (n ¼ 34,388). It should be noted that 87 cases met both the exclusion criteria. The final study cohort included 23,996 operations on patients with breast cancer with a PGY1 to PGY5 participant. Most of the patients were women (98.5%), with a mean age of 59.4 years. Elderly patients (at least 65 years old) accounted for 34.9% of cases. Chemotherapy was received within 30 days in 5.9% of patients, and 0.4% of patients received radiation therapy within the 90 days before operation. Only 1.7% of patients had disseminated cancer. PGY1 residents participated in the largest proportion of these cases (26.4%) when compared with residents from the other PGY levels (PGY2 [25.0%], PGY3 [20.1%], PGY4 [13.2%], and PGY5 [15.3%]). The inversely proportional relationship between case participation percentage and PGY represented a significant decreasing linear trend (p o 0.001). For each PGY level, less than 2% of cases were covered without an attending surgeon scrubbed into the operation. PGY4 residents performed the greatest percentage of cases without an attending surgeon scrubbed into the operation (1.4%). Cases covered by PGY1 residents were more likely to be outpatient operations (58.7%) when compared with operations involving residents of the other PGY levels (p o 0.001). Patients who were operated on with a PGY5 resident were significantly more likely to have Journal of Surgical Education Volume ]/Number ] ] 2015
received chemotherapy (7.5%) within 30 days of the operation than were those patients who had PGY1 to PGY4 residents participate in their care (p o 0.001). The participating resident’s PGY was not associated with the proportion of patients who received radiation therapy or had a history of disseminated cancer (Table 2). A total of 23,432 cases (97.7%) were assigned to a SCORE topic and complexity based on the CPT code. Of these cases, 93% (n ¼ 22,324) were assigned a complexity of essential-common, 1.9% (n ¼ 461) were assigned essential-uncommon, and 2.7% (n ¼ 647) were considered complex. The remaining 2.3% of cases were classified as other (Table 3). The frequency of essential-common breast cancer cases covered by residents declined with increasing PGY, with a nadir of 2905 cases during the PGY4 year. PGY4 and PGY5 residents covered 28.5% of all breast cancer cases (Fig.). The percentage of breast cancer cases classified as essentialcommon was inversely proportional to PGY, with only 90.5% of PGY5 cases being essential-common, when compared with 94.0% of PGY1 cases (p o 0.001). The essential-uncommon cases were relatively stable across years; however, the complex cases were predominantly covered by PGY1 and PGY2 residents (55.5%, p o 0.001). Additionally, there was a substantial increase in cases classified as other in the PGY5 year (4.7% of PGY5 cases, p o 0.001, Table 3). In the ACGME GSCL data for the academic period from 2007 to 2012, breast operations comprised 3.5% ⫾ 3.9% of the chief residents’ operative experience. For junior residents, the contribution of breast cases was 7.8% ⫾ 3.5%.
DISCUSSION Disparities in surgical management are seen between general surgeons and specialists when managing breast cancer. Specifically, it has been shown that patient satisfaction and the use of sentinel lymph node biopsy (SLNB), as well as mastectomy and reconstruction rates, correlate with increased surgeon specialization and case volume.20-22 Interestingly, in our study of surgical residents’ participation in the operative management of breast cancer, we found that residents at all levels of general surgery specialty training received exposure to common breast cancer cases. In this study, we demonstrated that most of the operations for breast cancer performed with resident involvement included a junior resident. However, we also showed that PGY4 and PGY5 residents did participate in the operative management of breast cancer. The participation of residents in breast surgery along the continuum of their residency training should permit senior-level residents to build on knowledge gained in the junior years. However, the current model may encourage junior residents to use the 3
0.29 0 0 0 0.63 0.67 SD, standard deviation.
26.4 6238 (98.6) 59.75 (13.6) 2276 (36) 28.22 (7.6) 3715 (58.7) (0) 6205 (98.1) 56 (0.9) 66 (1) 18 (0.3) 310 (4.9) 127.35 (96.7) 321 (5.1) 21 (0.3) 112 (1.8)
25.0 5923 (98.8) 59.35 (13.3) 2067 (34.5) 28.76 (7.6) 3099 (51.7) (0) 5917 (98.7) 28 (0.5) 49 (0.8) 17 (0.3) 298 (5) 139.98 (103.3) 344 (5.7) 23 (0.4) 97 (1.6)
20.1 4754 (98.5) 59.7 (13.4) 1717 (35.6) 28.79 (7.9) 2463 (51) (0) 4753 (98.4) 22 (0.5) 53 (1.1) 16 (0.3) 169 (3.5) 136.41 (99.3) 273 (5.7) 17 (0.4) 95 (2)
13.2 3108 (98) 59.3 (13.5) 1079 (34) 28.75 (7.8) 1466 (46.2) (0) 3098 (97.7) 43 (1.4) 31 (1) 17 (0.5) 129 (4.1) 141.55 (104.6) 209 (6.6) 18 (0.6) 55 (1.7)
15.3 3618 (98.4) 58.89 (13.6) 1247 (33.9) 28.7 (7.7) 1836 (50) (0) 3614 (98.3) 24 (0.7) 37 (1) 11 (0.3) 116 (3.2) 137.88 (99.3) 275 (7.5) 15 (0.4) 57 (1.6)
0
100 23,641 (98.5) 59.45 (13.5) 8386 (34.9) 28.61 (7.7) 12,579 (52.4) (0) 23,587 (98.3) 173 (0.7) 236 (1) 79 (0.3) 1022 (4.3) 135.82 (100.5) 1422 (5.9) 94 (0.4) 416 (1.7) % Of total cases Female Age, mean(SD) Age Z65 years BMI, mean (SD) Outpatient Level of resident supervision Attending surgeon and resident scrubbed Only resident scrubbed Other/not recorded Emergency case Prior operation within 30 days Total operation time, in minutes, mean (SD) Chemotherapy within 30 days Radiation therapy within 90 days Disseminated cancer
0.04 0.019 0.13 0.0001 0
Overall PGY1 PGY2 PGY3 PGY4 PGY5 n ¼ 23,996 (%) n ¼ 6327 (%) n ¼ 5994 (%) n ¼ 4828 (%) n ¼ 3172 (%) n ¼ 3675 (%) p Value Characteristic
TABLE 2. Patient Characteristics by PGY 4
common cases for the development of basic operative skills rather than developing a comprehensive understanding of breast cancer management. Based on the study findings, residents should have adequate exposure to breast cancer care to become proficient without advanced training; however, the data on disparities would argue that we can do a better job. The teaching faculty should remain mindful of the need to address the components of surgical decision making and nontechnical skills that are critical to the appropriate management of breast cancer when supervising residents. This is not different than for other disease processes; however, in this situation, we have data to suggest that most surgeons who treat breast cancer do not do subspecialty training8 and that the difference achieved across specialty and subspecialty providers is significant.20-22 It is known that surgeons who are new to practice rely on the knowledge learned during residency to care for their patients. For example, following the adoption of SLNB over axillary lymph node dissection for early-stage breast cancer in the early 2000s,23 a study was able to demonstrate that residency experience, not new standards, largely determined the use of SLNB by surgeons early in their career.24 This finding highlights the importance of a senior residents’ experience in breast cancer care. Experience at the senior level is important to emphasize the standard of care just before the transition to independent practice for residents who plan to manage breast cancer as a part of their practice. The essential-common operations, most often performed by junior residents, are the most likely procedures to be performed by young surgeons following the transition to a general surgical practice. To this point, an analysis of practice patterns from 2007 through 2009 indicates that general surgeons perform 90% of breast surgeries.8 The current job market for general surgeons does not require fellowship training for most positions25; therefore, patients seeking surgical care for these conditions must often rely on the knowledge gained during their surgeons’ residency training to ensure a good outcome. Our data confirm that the PGY4 and PGY5 residents did participate in breast surgery. Given the robust experience of the residents in their junior years, the opportunity to reinforce their knowledge and technical skills during the senior years with additional exposure should provide enough experience to safely meet the needs of the US population. In the ACGME GSCL data for the academic period from 2007 to 2012, breast operations comprised 3.5% ⫾ 3.9% of the chief residents’ operative experience. Furthermore, in examining the registry data, the operations covered by PGY5 residents were disproportionately weighted toward the complex cases and those classified as other, which may represent metastasectomy or tissue rearrangements. Chief residents are expected to spend their time on more complex cases to hone their technical skill. Trainees interested in broad-based general surgical practices or breast surgery who would like to enter practice immediately after residency Journal of Surgical Education Volume ]/Number ] ] 2015
TABLE 3. SCORE Topic and Complexity by PGY SCORE Complexity SCORE Patient Care Topic Essential-common Axillary lymphadenectomy Axillary SLNB Breast biopsy with or without needle localization Duct excision Lymph node biopsy Mastectomy—modified radical Mastectomy—partial Mastectomy—simple Subtotal Essential-uncommon Mastectomy—radical Complex Breast biopsy—image guided Other Other Total
PGY1 n (%)
PGY2 n (%)
PGY3 n (%)
PGY4 n (%)
PGY5 n (%)
Total n (%)
74 (1.2) 3 (0) 479 (7.6)
83 (1.4) (0) 362 (6)
74 (1.5) 2 (0) 267 (5.5)
28 (0.9) 2 (0.1) 153 (4.8)
53 (1.4) 1 (0) 147 (4)
312 (1.3) 8 (0) 1408 (5.9)
241 0 993 2241 1916 5947
(3.8) (0) (15.7) (35.4) (30.3) (94)
92 (1.5) 182 (2.9)
196 0 1174 1865 1948 5628
(3.3) (0) (19.6) (31.1) (32.5) (93.9)
93 (1.6) 177 (3)
151 3 1036 1418 1566 4517
(3.1) 59 (1.9) 48 (1.3) 695 (0.1) 0 (0) 0 (0) 3 (21.5) 811 (25.6) 1028 (28) 5042 (29.4) 769 (24.2) 921 (25.1) 7214 (32.4) 1083 (34.1) 1129 (30.7) 7642 (93.6) 2905 (91.6) 3327 (90.5) 22324
(2.9) (0) (21) (30.1) (31.8) (93)
101 (2.1)
87 (2.7)
88 (2.4)
461 (1.9)
135 (2.8)
65 (2)
88 (2.4)
647 (2.7)
106 (1.7) 96 (1.6) 75 (1.6) 115 (3.6) 172 (4.7) 564 (2.4) 6327 (100) 5994 (100) 4828 (100) 3172 (100) 3675 (100) 23996 (100)
should consider requesting an elective on a comprehensive breast service in the PGY4. This would enable the residents to enhance the experience in breast cancer care before entering practice without missing out on the management of complex gastrointestinal cases that may be important for their practice or preparation for board examinations as a PGY5 resident. Until board certification and credentialing becomes predicated on actual practice case mix, each resident must achieve competence in the full complement of general surgery operations. There is no defined method for determining the effect that the timing of an aspect of a resident’s training would have on his or her independent practices.
For breast cancer, a comprehensive analysis of this kind would require knowledge of the performance of residents on the breast disease component of their qualifying and certifying examinations, as well as longitudinal data of practice patterns and patient outcomes attributed to each resident. At this time, no such data set exists, although the authors of this study remain optimistic that this type of data will be developed in the future. This study is limited by the nature of the ACS NSQIP PUF. In particular, hospital and residency training program characteristics are not released, and the individual resident’s experience may be highly variable and influenced by the environment in which he or she is training. Despite this
FIGURE. Number of breast cancer cases at each PGY by complexity. Journal of Surgical Education Volume ]/Number ] ] 2015
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issue, understanding the data in aggregate would permit the initiation of dialogue regarding a more comprehensive approach to training standardization to minimize disparities after the transition to practice. The treatment of breast cancer may include surgical metastasectomy. Metastasectomy would likely represent the most complex procedure performed during the operation; however, because the location of the metastasis is unknown and we wanted to limit our study to general surgery, our results may underrepresent the number of complex procedures performed.
CONCLUSIONS This examination of the surgical residents’ experience in breast cancer operations demonstrated that experience with breast surgery is obtained across the residency training period. Therefore, the operative experience with breast cancer care should be sufficient to learn the appropriate approach to breast surgery. Future studies to examine residents’ experience with the nontechnical skills required for the optimal care of patients with breast cancer are needed to attempt to eradicate outcome disparities for patients with breast cancer.
7. Skinner KA, Helsper JT, Deapen D, et al. Breast
cancer: do specialists make a difference? Ann Surg Oncol. 2003;10:606-615. 8. Valentine RJ, Jones A, Biester TW, et al. General
surgery workloads and practice patterns in the United States, 2007 to 2009: a 10-year update from the American Board of Surgery. Ann Surg. 2011;254 520-525. [discussion 525-6]. 9. Richardson JD. General surgeon shortage in the
United States: fact or fiction, causes and consequences. Soc Work Pub Health. 2011;26:513-523.
10. Sheldon GF. The evolving surgeon shortage in the
health reform era. J Gastrointest Surg. 2011;15: 1104-1111. 11. Ko C, Chaudhry S. The need for a multidisciplinary
approach to cancer care. J Surg Res. 2002;105:53-57. 12. Sachdeva AK, Bell RH Jr, Britt LD, et al. National
efforts to reform residency education in surgery. Acad Med. 2007;82:1200-1210. 13. American College of Surgeons National Surgical Quality
Improvement Program. “User Guide for the 2010 Participant Use Data File”; 2012.
14. Shiloach M, Frencher SK Jr, Steeger JE, et al. Toward
REFERENCES 1. U.S. Cancer Statistics Working Group. United States
Cancer Statistics: 1999-2010 Incidence and Mortality Web-based Report; 2013. 2. Grilli R, Minozzi S, Tinazzi A, et al. Do specialists do
it better? The impact of specialization on the processes and outcomes of care for cancer patients Ann Oncol. 1998;9:365-374. 3. Hillner BE, Smith TJ, Desch CE. Hospital and
physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care. J Clin Oncol. 2000;18:2327-2340. 4. Allgood PC, Bachmann MO. Effects of specialisation
on treatment and outcomes in screen-detected breast cancers in Wales: cohort study. Br J Cancer. 2006;94: 36-42. 5. Zork NM, Komenaka IK, Pennington RE Jr, et al.
The effect of dedicated breast surgeons on the shortterm outcomes in breast cancer. Ann Surg. 2008;248: 280-285. 6. Bilimoria KY, Phillips JD, Rock CE, et al. Effect of
surgeon training, specialization, and experience on outcomes for cancer surgery: a systematic review of the literature. Ann Surg Oncol. 2009;16:1799-1808. 6
robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210:6-16. 15. Fryer J, Corcoran N, DaRosa D. Use of the Surgical
Council on Resident Education (SCORE) curriculum as a template for evaluating and planning a program’s clinical curriculum. J Surg Educ. 2010;67:52-57. 16. Bell RH. Surgical council on resident education: a new
organization devoted to graduate surgical education. J Am Coll Surg. 2007;204:341-346. 17. Surgical Council on Resident Education. Curriculum
outline for general surgery residency: 2013-2014. 18. Juul S, Frydenberg M. An Introduction to Stata for
Health Researchers. 3rd ed College Station, TX: Stata Press; 2010. 179-196. 19. Accreditation Council for Graduate Medical Education.
General Surgery Case Logs: National Data Report, 2007-2012; 2014. 20. Waljee JF, Hawley S, Alderman AK, et al. Patient
satisfaction with treatment of breast cancer: does surgeon specialization matter? J Clin Oncol. 2007;25: 3694-3698. 21. Yen TW, Laud PW, Sparapani RA, Nattinger AB.
Surgeon specialization and use of sentinel lymph node Journal of Surgical Education Volume ]/Number ] ] 2015
biopsy for breast cancer. JAMA Surg. 2014;149: 185-192.
24. Vanderveen KA, Paterniti DA, Kravitz RL, Bold RJ.
between-surgeon variation in breast cancer treatments. Med Care. 2006;44:609-616.
Diffusion of surgical techniques in early stage breast cancer: variables related to adoption and implementation of sentinel lymph node biopsy. Ann Surg Oncol. 2007;14:1662-1669.
23. Lyman GH, Giuliano AE, Somerfield MR, et al.
25. Decker MR, Bronson NW, Greenberg CC, et al. The
American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in earlystage breast cancer. J Clin Oncol. 2005;23:7703-7720.
general surgery job market: analysis of current demand for general surgeons and their specialized skills. J Am Coll Surg. 2013;217:1133-1139.
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22. Hawley ST, Hofer TP, Janz NK, et al. Correlates of
Residents’ Experience in Breast Cancer Care$ R. Gregory Conway, MD, Edmund K. Bartlett, MD, Rebecca L. Hoffman, MD, Brian J. Czerniecki, MD, PhD, Giorgos C. Karakousis, MD, FACS and Rachel R. Kelz, MD, MSCE, FACS Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania OBJECTIVE: General surgeons commonly treat breast cancer (BC), hence necessitating adequate training during residency. We examined surgery residents’ exposure to these conditions across postgraduate years (PGYs) to assess the proximity of involvement to commencement.
KEY WORDS: breast cancer, NSQIP, oncology, resident,
SCORE COMPETENCIES: Patient Care, Medical Knowledge, Practice-Based Learning
STUDY DESIGN: We examined the BC operative profile
by PGY using the American College of Surgeons National Surgical Quality Improvement Program Participant Use File (ACS NSQIP PUF, 2008-2011). Operations were classified using the Surgical Council on Resident Education curriculum complexity categories. Univariate analysis was performed using chi-square, Fisher exact, analysis of variance, and Kruskal-Wallis tests, as appropriate. RESULTS: Of 58,413 BC operations, 23,996 involved PGY1 to PGY5 residents. A Surgical Council on Resident Education complexity was assigned to 97.7% of operations studied (n ¼ 23,432). PGY was inversely proportional to the number of operations performed. PGY1 to PGY3 residents covered most essential-common operations (PGY1-3, 72% vs PGY4-5, 28%; p o 0.001). PGY1 and PGY2 residents covered more than half of the complex operations (PGY1-2, 55% [n ¼ 359] vs PGY3-5, 45% [n ¼ 288]; p ¼ 0.033). CONCLUSIONS: Although junior residents perform most
of the BC cases in surgical residency, residents do participate in operations for BC across the continuum of the training years. Program directors should consider trainees’ career aspirations to ensure adequate exposure to the operative and nonoperative management of this common disease before C the transition to independent practice. ( J Surg ]:]]]-]]]. J 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) ☆ The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein. The Accreditation Council for Graduate Medical Education—General Surgery Case Log data were used for analysis in this study. The analysis and interpretation of the results is the sole responsibility of the authors. The data providers are not responsible for any statistical validity of the data analysis or the conclusions derived by the authors. Correspondence: Inquiries to Rachel R. Kelz, MD, MSCE, FACS, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA 19104; fax: (215) 662-7476; e-mail: [email protected]
INTRODUCTION Breast cancer has an incidence rate of 121.9 per 100,000 people, making the disease the most common cancer in women in the United States.1 Surgery is the mainstay of curative therapy for this disease. Surgeon volume and specialty training are associated with both short- and longterm oncologic outcomes.2-7 Despite the known association between fellowship training and cancer care, general surgeons perform a substantial proportion of breast cancer surgery.8 Technically, this approach is reasonable because the operations, for the most part, can be performed using techniques learned during general surgery residency. Furthermore, as there exists a shortage and maldistribution of surgeons, specialty training is not practical when considering the needs of the population as a whole.9,10 However, breast cancer treatment requires a multidisciplinary approach coupled with up-to-date knowledge of best practice guidelines to achieve optimal patient outcomes.11 Therefore, exposure during the general surgery residency must provide training that would be valuable at the time of the transition to practice in order to benefit the patients treated by these surgeons. Surgical education has a long tradition of introducing residents first to common essential operations, followed by a focus on more technically demanding complex operations. This approach is necessary to permit a graduated level of responsibility and autonomy without the unnecessary exposure of patients to risk. More recently, it has been recognized that the types of procedures and diseases seen during residency are not always representative of the types of procedures performed and diseases treated by practicing general surgeons.12 Frequently, for diseases such as breast cancer, the technical complexity of the operation is unrelated to the
Journal of Surgical Education & 2015 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.2015.04.028
1
cognitive complexity of the patient management. As surgical exposure is often centered on operative complexity, senior surgical residents may not receive adequate exposure immediately before graduation. Therefore, we sought to examine the exposure of general surgery residents to breast cancer operations by postgraduate year (PGY) of training to understand the proximity of their experience to their transition to practice.
MATERIAL AND METHODS Data source We identified patients recorded in the American College of Surgeons National Surgical Quality Improvement Program Participant Use File (ACS NSQIP PUF, fiscal year: 20082011) with a postoperative diagnosis of breast cancer using the International Classification of Diseases Ninth Revision diagnosis codes (174, 174.0-174.6, 174.8, 174.9, 175, 175.0, and 175.9). Patients were included in the study if they underwent an operation for the treatment of breast cancer using the Current Procedural Terminology (CPT) codes (Table 1) and a PGY1 to PGY5 level resident participated in the operation. Resident level was assigned using the PGY in training of the resident as recorded in the ACS NSQIP database. The ACS NSQIP PUF contains data on 252 variables, including preoperative risk factors, intraoperative variables, and morbidity and mortality outcomes in both the inpatient and the outpatient settings. The 2011 sample, for example, contains data on 442,149 cases from 315 participating sites. The sampling procedure selects completed cases from hospital operative logs on an 8-day cycle. This method captures data for the first 40 consecutive cases meeting the inclusion/exclusion criteria for the cycle for high-volume hospitals. For low-volume hospitals, all cases meeting the inclusion/exclusion criteria are collected.13 Data collection
Essential-common Axillary lymphadenectomy Axillary SLNB Breast biopsy with or without needle localization Duct excision Lymph node biopsy Mastectomy—modified radical Mastectomy—partial Mastectomy—simple Essential-uncommon Mastectomy—radical Complex Breast biopsy—image guided 2
Procedures were classified using the Surgical Council on Resident Education (SCORE) complexity categories. The SCORE curriculum was created in an effort to standardize surgical resident training,12,15,16 and it not only classifies procedural competencies based on technical complexity but also provides a framework for resident knowledge. The CPT codes recorded for each case were mapped to educational topics defined by the SCORE curriculum. Complexity values were assigned to each case based on the most complex procedure performed by the primary surgical team. Procedures that did not align with these categories were assigned a complexity of “other.” The assignment of a CPT code to a SCORE topic is shown in Table 1. The SCORE curriculum defines 3 complexity categories17: 1. Essential-common: Frequently performed operations in general surgery; specific procedure competency is required by end of training. 2. Essential-uncommon: Uncommon, often urgent, operations seen in general surgery practice and not typically done in significant numbers by residents; specific procedure competency required by the end of training (but cannot be attained by case volume alone). 3. Complex: Not consistently performed by general surgeons in training and not typically performed in general surgery practice. Generic experience in complex procedures is required but not competence in individual procedures. Some residency programs may provide sufficient experience for competence in some specific procedures.
19112, 19120 38510, 38520 19302 19303, 19304
Statistical Analysis
CPT Codes 38525, 38740, 38745 38792, 38900 19101, 19125 19110, 38500, 19307 19301, 19300,
Variable Definitions
Patient variables of interest included age, gender, the American Society of Anesthesiology Physical Status Classification (ASA class), estimated probability of morbidity and mortality, body mass index, and elderly status (65 years and older). Operative variables examined included inpatient/ outpatient status, level of resident supervision (presence of an attending physician), total operation time, emergency case, and previous operation within 30 days. Oncologic variables of interest include chemotherapy within 30 days of the operation, radiation therapy within 90 days, and the presence of disseminated cancer.
TABLE 1. Assignment of SCORE Topic and SCORE Complexity to CPT Codes SCORE Complexity SCORE patient care topic
personnel who populate the ACS NSQIP database undergo thorough training, and internal audit procedures have been found to be highly effective in ensuring data reliability.14
19305, 19306 19290, 19291, 19295
Descriptive statistics were examined. Univariate analyses were performed using chi-square or Fisher exact tests for categorical variables and analysis of variance or KruskalJournal of Surgical Education Volume ]/Number ] ] 2015
Wallis tests for continuous variables, as appropriate. To evaluate whether there was a significant trend in proportion of case participation by PGY, a nonparametric trend test for the analysis of proportions was performed. A p o 0.05 was considered statistically significant. Statistical analysis was performed using Stata 12.0/IC statistical software (StataCorp, College Station, TX).18 This study was approved by the University of Pennsylvania’s Institutional Review Board and deemed exempt from continuing review. In an effort to evaluate our results in the context of the national experience with breast surgery by PGY, we also analyzed the Accreditation Council for Graduate Medical Education (ACGME) General Surgery Case Log (GSCL) data for breast surgeries.19 The ACGME GSCL data set is the centralized repository of resident operative experience across all ACGME-accredited general surgery residency programs. Residents are expected to log all operations in which they participated over the 5 years of their surgical residency. Procedures are categorized based on the resident review committee subject area, and we identified surgeries categorized as breast related. The number of operations are tabulated by the surgeon chief, the surgeon junior, and overall. Percentages were calculated from these tables.
RESULTS We identified 58,413 patients with breast cancer. Patients were excluded from the study for missing information on surgical specialty (n ¼ 116) or missing PGY information (n ¼ 34,388). It should be noted that 87 cases met both the exclusion criteria. The final study cohort included 23,996 operations on patients with breast cancer with a PGY1 to PGY5 participant. Most of the patients were women (98.5%), with a mean age of 59.4 years. Elderly patients (at least 65 years old) accounted for 34.9% of cases. Chemotherapy was received within 30 days in 5.9% of patients, and 0.4% of patients received radiation therapy within the 90 days before operation. Only 1.7% of patients had disseminated cancer. PGY1 residents participated in the largest proportion of these cases (26.4%) when compared with residents from the other PGY levels (PGY2 [25.0%], PGY3 [20.1%], PGY4 [13.2%], and PGY5 [15.3%]). The inversely proportional relationship between case participation percentage and PGY represented a significant decreasing linear trend (p o 0.001). For each PGY level, less than 2% of cases were covered without an attending surgeon scrubbed into the operation. PGY4 residents performed the greatest percentage of cases without an attending surgeon scrubbed into the operation (1.4%). Cases covered by PGY1 residents were more likely to be outpatient operations (58.7%) when compared with operations involving residents of the other PGY levels (p o 0.001). Patients who were operated on with a PGY5 resident were significantly more likely to have Journal of Surgical Education Volume ]/Number ] ] 2015
received chemotherapy (7.5%) within 30 days of the operation than were those patients who had PGY1 to PGY4 residents participate in their care (p o 0.001). The participating resident’s PGY was not associated with the proportion of patients who received radiation therapy or had a history of disseminated cancer (Table 2). A total of 23,432 cases (97.7%) were assigned to a SCORE topic and complexity based on the CPT code. Of these cases, 93% (n ¼ 22,324) were assigned a complexity of essential-common, 1.9% (n ¼ 461) were assigned essential-uncommon, and 2.7% (n ¼ 647) were considered complex. The remaining 2.3% of cases were classified as other (Table 3). The frequency of essential-common breast cancer cases covered by residents declined with increasing PGY, with a nadir of 2905 cases during the PGY4 year. PGY4 and PGY5 residents covered 28.5% of all breast cancer cases (Fig.). The percentage of breast cancer cases classified as essentialcommon was inversely proportional to PGY, with only 90.5% of PGY5 cases being essential-common, when compared with 94.0% of PGY1 cases (p o 0.001). The essential-uncommon cases were relatively stable across years; however, the complex cases were predominantly covered by PGY1 and PGY2 residents (55.5%, p o 0.001). Additionally, there was a substantial increase in cases classified as other in the PGY5 year (4.7% of PGY5 cases, p o 0.001, Table 3). In the ACGME GSCL data for the academic period from 2007 to 2012, breast operations comprised 3.5% ⫾ 3.9% of the chief residents’ operative experience. For junior residents, the contribution of breast cases was 7.8% ⫾ 3.5%.
DISCUSSION Disparities in surgical management are seen between general surgeons and specialists when managing breast cancer. Specifically, it has been shown that patient satisfaction and the use of sentinel lymph node biopsy (SLNB), as well as mastectomy and reconstruction rates, correlate with increased surgeon specialization and case volume.20-22 Interestingly, in our study of surgical residents’ participation in the operative management of breast cancer, we found that residents at all levels of general surgery specialty training received exposure to common breast cancer cases. In this study, we demonstrated that most of the operations for breast cancer performed with resident involvement included a junior resident. However, we also showed that PGY4 and PGY5 residents did participate in the operative management of breast cancer. The participation of residents in breast surgery along the continuum of their residency training should permit senior-level residents to build on knowledge gained in the junior years. However, the current model may encourage junior residents to use the 3
0.29 0 0 0 0.63 0.67 SD, standard deviation.
26.4 6238 (98.6) 59.75 (13.6) 2276 (36) 28.22 (7.6) 3715 (58.7) (0) 6205 (98.1) 56 (0.9) 66 (1) 18 (0.3) 310 (4.9) 127.35 (96.7) 321 (5.1) 21 (0.3) 112 (1.8)
25.0 5923 (98.8) 59.35 (13.3) 2067 (34.5) 28.76 (7.6) 3099 (51.7) (0) 5917 (98.7) 28 (0.5) 49 (0.8) 17 (0.3) 298 (5) 139.98 (103.3) 344 (5.7) 23 (0.4) 97 (1.6)
20.1 4754 (98.5) 59.7 (13.4) 1717 (35.6) 28.79 (7.9) 2463 (51) (0) 4753 (98.4) 22 (0.5) 53 (1.1) 16 (0.3) 169 (3.5) 136.41 (99.3) 273 (5.7) 17 (0.4) 95 (2)
13.2 3108 (98) 59.3 (13.5) 1079 (34) 28.75 (7.8) 1466 (46.2) (0) 3098 (97.7) 43 (1.4) 31 (1) 17 (0.5) 129 (4.1) 141.55 (104.6) 209 (6.6) 18 (0.6) 55 (1.7)
15.3 3618 (98.4) 58.89 (13.6) 1247 (33.9) 28.7 (7.7) 1836 (50) (0) 3614 (98.3) 24 (0.7) 37 (1) 11 (0.3) 116 (3.2) 137.88 (99.3) 275 (7.5) 15 (0.4) 57 (1.6)
0
100 23,641 (98.5) 59.45 (13.5) 8386 (34.9) 28.61 (7.7) 12,579 (52.4) (0) 23,587 (98.3) 173 (0.7) 236 (1) 79 (0.3) 1022 (4.3) 135.82 (100.5) 1422 (5.9) 94 (0.4) 416 (1.7) % Of total cases Female Age, mean(SD) Age Z65 years BMI, mean (SD) Outpatient Level of resident supervision Attending surgeon and resident scrubbed Only resident scrubbed Other/not recorded Emergency case Prior operation within 30 days Total operation time, in minutes, mean (SD) Chemotherapy within 30 days Radiation therapy within 90 days Disseminated cancer
0.04 0.019 0.13 0.0001 0
Overall PGY1 PGY2 PGY3 PGY4 PGY5 n ¼ 23,996 (%) n ¼ 6327 (%) n ¼ 5994 (%) n ¼ 4828 (%) n ¼ 3172 (%) n ¼ 3675 (%) p Value Characteristic
TABLE 2. Patient Characteristics by PGY 4
common cases for the development of basic operative skills rather than developing a comprehensive understanding of breast cancer management. Based on the study findings, residents should have adequate exposure to breast cancer care to become proficient without advanced training; however, the data on disparities would argue that we can do a better job. The teaching faculty should remain mindful of the need to address the components of surgical decision making and nontechnical skills that are critical to the appropriate management of breast cancer when supervising residents. This is not different than for other disease processes; however, in this situation, we have data to suggest that most surgeons who treat breast cancer do not do subspecialty training8 and that the difference achieved across specialty and subspecialty providers is significant.20-22 It is known that surgeons who are new to practice rely on the knowledge learned during residency to care for their patients. For example, following the adoption of SLNB over axillary lymph node dissection for early-stage breast cancer in the early 2000s,23 a study was able to demonstrate that residency experience, not new standards, largely determined the use of SLNB by surgeons early in their career.24 This finding highlights the importance of a senior residents’ experience in breast cancer care. Experience at the senior level is important to emphasize the standard of care just before the transition to independent practice for residents who plan to manage breast cancer as a part of their practice. The essential-common operations, most often performed by junior residents, are the most likely procedures to be performed by young surgeons following the transition to a general surgical practice. To this point, an analysis of practice patterns from 2007 through 2009 indicates that general surgeons perform 90% of breast surgeries.8 The current job market for general surgeons does not require fellowship training for most positions25; therefore, patients seeking surgical care for these conditions must often rely on the knowledge gained during their surgeons’ residency training to ensure a good outcome. Our data confirm that the PGY4 and PGY5 residents did participate in breast surgery. Given the robust experience of the residents in their junior years, the opportunity to reinforce their knowledge and technical skills during the senior years with additional exposure should provide enough experience to safely meet the needs of the US population. In the ACGME GSCL data for the academic period from 2007 to 2012, breast operations comprised 3.5% ⫾ 3.9% of the chief residents’ operative experience. Furthermore, in examining the registry data, the operations covered by PGY5 residents were disproportionately weighted toward the complex cases and those classified as other, which may represent metastasectomy or tissue rearrangements. Chief residents are expected to spend their time on more complex cases to hone their technical skill. Trainees interested in broad-based general surgical practices or breast surgery who would like to enter practice immediately after residency Journal of Surgical Education Volume ]/Number ] ] 2015
TABLE 3. SCORE Topic and Complexity by PGY SCORE Complexity SCORE Patient Care Topic Essential-common Axillary lymphadenectomy Axillary SLNB Breast biopsy with or without needle localization Duct excision Lymph node biopsy Mastectomy—modified radical Mastectomy—partial Mastectomy—simple Subtotal Essential-uncommon Mastectomy—radical Complex Breast biopsy—image guided Other Other Total
PGY1 n (%)
PGY2 n (%)
PGY3 n (%)
PGY4 n (%)
PGY5 n (%)
Total n (%)
74 (1.2) 3 (0) 479 (7.6)
83 (1.4) (0) 362 (6)
74 (1.5) 2 (0) 267 (5.5)
28 (0.9) 2 (0.1) 153 (4.8)
53 (1.4) 1 (0) 147 (4)
312 (1.3) 8 (0) 1408 (5.9)
241 0 993 2241 1916 5947
(3.8) (0) (15.7) (35.4) (30.3) (94)
92 (1.5) 182 (2.9)
196 0 1174 1865 1948 5628
(3.3) (0) (19.6) (31.1) (32.5) (93.9)
93 (1.6) 177 (3)
151 3 1036 1418 1566 4517
(3.1) 59 (1.9) 48 (1.3) 695 (0.1) 0 (0) 0 (0) 3 (21.5) 811 (25.6) 1028 (28) 5042 (29.4) 769 (24.2) 921 (25.1) 7214 (32.4) 1083 (34.1) 1129 (30.7) 7642 (93.6) 2905 (91.6) 3327 (90.5) 22324
(2.9) (0) (21) (30.1) (31.8) (93)
101 (2.1)
87 (2.7)
88 (2.4)
461 (1.9)
135 (2.8)
65 (2)
88 (2.4)
647 (2.7)
106 (1.7) 96 (1.6) 75 (1.6) 115 (3.6) 172 (4.7) 564 (2.4) 6327 (100) 5994 (100) 4828 (100) 3172 (100) 3675 (100) 23996 (100)
should consider requesting an elective on a comprehensive breast service in the PGY4. This would enable the residents to enhance the experience in breast cancer care before entering practice without missing out on the management of complex gastrointestinal cases that may be important for their practice or preparation for board examinations as a PGY5 resident. Until board certification and credentialing becomes predicated on actual practice case mix, each resident must achieve competence in the full complement of general surgery operations. There is no defined method for determining the effect that the timing of an aspect of a resident’s training would have on his or her independent practices.
For breast cancer, a comprehensive analysis of this kind would require knowledge of the performance of residents on the breast disease component of their qualifying and certifying examinations, as well as longitudinal data of practice patterns and patient outcomes attributed to each resident. At this time, no such data set exists, although the authors of this study remain optimistic that this type of data will be developed in the future. This study is limited by the nature of the ACS NSQIP PUF. In particular, hospital and residency training program characteristics are not released, and the individual resident’s experience may be highly variable and influenced by the environment in which he or she is training. Despite this
FIGURE. Number of breast cancer cases at each PGY by complexity. Journal of Surgical Education Volume ]/Number ] ] 2015
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issue, understanding the data in aggregate would permit the initiation of dialogue regarding a more comprehensive approach to training standardization to minimize disparities after the transition to practice. The treatment of breast cancer may include surgical metastasectomy. Metastasectomy would likely represent the most complex procedure performed during the operation; however, because the location of the metastasis is unknown and we wanted to limit our study to general surgery, our results may underrepresent the number of complex procedures performed.
CONCLUSIONS This examination of the surgical residents’ experience in breast cancer operations demonstrated that experience with breast surgery is obtained across the residency training period. Therefore, the operative experience with breast cancer care should be sufficient to learn the appropriate approach to breast surgery. Future studies to examine residents’ experience with the nontechnical skills required for the optimal care of patients with breast cancer are needed to attempt to eradicate outcome disparities for patients with breast cancer.
7. Skinner KA, Helsper JT, Deapen D, et al. Breast
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surgery workloads and practice patterns in the United States, 2007 to 2009: a 10-year update from the American Board of Surgery. Ann Surg. 2011;254 520-525. [discussion 525-6]. 9. Richardson JD. General surgeon shortage in the
United States: fact or fiction, causes and consequences. Soc Work Pub Health. 2011;26:513-523.
10. Sheldon GF. The evolving surgeon shortage in the
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approach to cancer care. J Surg Res. 2002;105:53-57. 12. Sachdeva AK, Bell RH Jr, Britt LD, et al. National
efforts to reform residency education in surgery. Acad Med. 2007;82:1200-1210. 13. American College of Surgeons National Surgical Quality
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14. Shiloach M, Frencher SK Jr, Steeger JE, et al. Toward
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22. Hawley ST, Hofer TP, Janz NK, et al. Correlates of