- Email: [email protected]
Trends in Pediatric Surgery Operative Volume among Residents and Fellows: Improving the Experience for All
Trends in Pediatric Surgery Operative Volume among Residents and Fellows: Improving the Experience for All Stephanie Talutis, MD, MPH, David McAneny, MD, FACS, Catherine Chen, Gerard Doherty, MD, FACS, Teviah Sachs, MD, MPH
MD, MPH, FACS,
The ACGME requires general surgery residents (GSR) to perform 20 pediatric surgery cases as part of the total 750 cases before graduation. STUDY DESIGN: We queried the ACGME General Surgery (1999 to 2014) and Pediatric Surgery (2003 to 2014) Case Logs for all pediatric operations performed during training. Means (SD) and medians (10th:90th percentiles) were compared, and R2 was calculated for all trends. RESULTS: The number of pediatric surgery fellows (PSF) increased 63% (23 to 39; R2 ¼ 0.82), while GSR numbers increased 12% (989 to 1,105; R2 ¼ 0.77). Total and average pediatric surgery case volume for GSR decreased from 39,309 to 32,156 (R2 ¼ 0.90) and 39.7 13 to 29.1 10 (R2 ¼ 0.91), respectively. Meanwhile, average PSF case volume increased from 980 208 to 1,137 202 (R2 ¼ 0.83). These trends persisted for inguinal/umbilical hernia (GSR 22.1 13 to 15.6 10; R2 ¼ 0.93; PSF 90.5 17.6 to 104.4 20.7; R2 ¼ 0.34), pyloric stenosis (GSR 3.9 3 to 2.8 3; R2 ¼ 0.60; PSF 29.6 15 to 39.7 16.8; R2 ¼ 0.69), and intestinal atresia (GSR 1.3 2 to 1.1 2; R2 ¼ 0.34; PSF 4.3 4 to 11.8 8; R2 ¼ 0.21). The mean number of GSR pediatric operations diminished for both junior (37.1 20 to 27.3 16; R2 ¼ 0.88) and chief (2.6 5 to 1.7 5; R2 ¼ 0.75) years. Teaching cases in pediatric surgery decreased at all levels. Although the percentage of GSR teaching cases performed during chief years fell modestly (6.6% to 4.7%; R2 ¼ 0.53), median teaching cases dropped from 2 (0:11 [10th:90th percentiles]) to zero (0:0 [10th:90th percentiles]). Mean PSF teaching cases declined (100.7 396 to 44.5 42; R2 ¼ 0.72), while the percentage of operations that were teaching cases decreased more sharply (10.3% to 3.5%; R2 ¼ 0.82). CONCLUSIONS: Total pediatric surgery cases and PSF operative volume have increased, while GSR operative volume has decreased. Opportunities may exist to increase resident participation while providing further teaching opportunities for GSR, improving the quality of both resident and fellow training. (J Am Coll Surg 2016;222:1082e1088. 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)
BACKGROUND:
The Accreditation Council for Graduate Medical Education (ACGME) has established criteria for graduation from general surgery residency programs, including target case volumes by categories, such as trauma, vascular, and Disclosure Information: Nothing to disclose. Presented at the 96th Annual Meeting of the New England Surgical Society, Newport, RI, September 2015. Received October 17, 2015; Revised November 19, 2015; Accepted November 19, 2015. From the Departments of Surgery, Boston Medical Center, Boston University School of Medicine (Talutis, McAneny, Doherty, Sachs) and Boston Children’s Hospital, Harvard Medical School (Chen), Boston, MA. Correspondence address: Teviah Sachs, MD, MPH, Department of Surgical Oncology, Boston Medical Center, 820 Harrison Ave, FGH Building - Suite 5007, Boston, MA 02118. email: [email protected]
ª 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
pediatrics.1-4 The ACGME currently requires that general surgery residents perform a minimum of 750 cases, of which 20 must be identified as pediatric surgery cases (defined as patients under the age of 13) before graduation. This is divided into subgroups of umbilical/inguinal herniorrhaphy (n ¼ 8), appendectomy (n ¼ 6), and unspecified cases (n ¼ 6).4 The ACGME similarly has established requirements for graduation from pediatric surgery fellowship. Fellows are required to log 800 major pediatric surgical cases as primary surgeon during the 2 years of fellowship, with at least 25 operative resections of tumors and 75 neonatal cases.1 Although minimum requirements for operative volume exist within both general surgery residency programs and
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pediatric surgery fellowship programs, there are no data that ensure competency based on these figures.5,6 Pediatric surgical education for residents varies greatly among residency programs and institutions, and it is often limited to a few months during the entire 5-year general surgery residency.2,4 Beyond operative requirements, residents are responsible for the diagnosis and management of pediatric surgery patients.4 Given the limited exposure of residents to this discipline, it is critical that residents receive optimal exposure, education, and experience during pediatric surgery rotations.2 This experience presumably ensures a minimum competency in pediatric surgery for graduating residents.1 Our previous reports of trends in operative experiences of general surgery residents over time have revealed decreases in the number of cases residents perform, overall and in the role of teaching resident.3,7 Little is known about the pediatric surgery experiences of graduating residents and fellows over time. We sought to evaluate trends in operative case volume for general surgery residents and pediatric surgery fellows to identify possible strategies to improve the education of both groups.
METHODS The ACGME general surgery and pediatric surgery databases are based on all operations reported by residents and fellows, respectively. The number of operations in each category (eg, pediatric, breast, endocrine, etc) is tabulated and stratified according to the resident’s operative role: surgeon chief (cases performed during chief year), surgeon junior (all cases performed during the preceding years in which the resident was the primary surgeon), and teaching assistant (cases in which a senior resident guides a junior resident through the case). The aggregate number of cases for all 5 years, excluding first assistant cases, comprises the “surgeon total,” which is essential for graduating residents to receive credit toward certification. There is an additional category for first assistant (cases in which a resident observes and assists when needed); however, this category does not count toward graduate requirements. Similar data are recorded for pediatric surgery fellows. The operative role of fellows is specifically categorized by type of operation and stratified into total surgeon and teaching assistant. The ACGME database provides means, standard deviations, medians, and stratified percentiles (10th, 30th, 50th, 70th, and 90th) for the operative categories. We queried the ACGME database for overall case volume as well as total and operation-specific pediatric surgery case volume of graduating chief residents between 1999 and 2014. Data for pediatric surgery fellows were also queried and were available from 2003 to 2014. Operation-specific volume was further analyzed for fellow
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cases that could be matched to those available for residents (ie, hernia repair, repair of pyloric stenosis, etc). Standard measures of operative volumes using mean and total case volumes were identified. For years during which total case volumes were not provided (2010 to 2014), estimates were calculated using the total number of residents and the mean case volume for a particular operation. Certain operative categories within pediatric surgery fellow data are divided into open and laparoscopic operations. For the purposes of comparison analysis to general surgery resident case volume, where no such categorization exists, these subcategories were combined and presented as totals for the categories of herniorrhaphy, repair of pyloric stenosis, operation for malrotation or intussusception, operation for meconium ileus or necrotizing enterocolitis, and definitive operation for Hirschsprung’s disease or imperforate anus. We further identified percentiles (10%, 50%, and 90%) for both pediatric surgery and total teaching case volumes for general surgery residents to evaluate trends in teaching cases over time. Both means (SD) and medians (10th:90th percentiles) are presented. Raw data are not available through the ACGME, precluding the application of certain statistical models. However, linear data trends were examined by assessing a goodness of fit model based on the means presented and reported as the value of R2 (range 0 to 1).
RESULTS From 1999 to 2014, the total number of general surgery residents increased 12% (989 to 1,105; R2 ¼ 0.77). Total general surgery case volume similarly increased 14% during this interval, from 955,858 to 1,085,331 cases (R2 ¼ 0.83); the average number of cases performed by general surgery residents remained stable (996.5 204 to 982.2 162 cases; R2 ¼ 0.09). During the same period of time, the total number of pediatric surgery cases performed by graduating chief residents declined 18.2%, from 39,309 to 32,156 (R2 ¼ 0.90). The average number of pediatric surgery cases performed by general surgery residents decreased by 26.7%, from 39.7 19 to 29.1 16 (R2 ¼ 0.91). This was evident both for cases recorded during junior resident (37.1 20 to 27.3 16; R2 ¼ 0.88) and chief resident years (2.6 5 to 1.7 5; R2 ¼ 0.75) (Fig. 1). Between 2003 and 2014, the number of pediatric surgery fellows increased by 63% (23 to 39; R2 ¼ 0.82). In addition, the average pediatric surgery fellow case volume during this interval increased by 16%, from 980 208 to 1,167 145 (R2 ¼ 0.87). Similarly, total cases performed by pediatric surgery fellows increased 49.3%, from 23,516 to 46,363 (R2 ¼ 0.90). The decreasing number of total and average pediatric surgery operations logged by general surgery residents
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Figure 1. Trends in pediatric surgery case volume over time (means: resident and fellow).
coincided with an increase in the total and average number of operations logged by pediatric surgery fellows (Table 1). In an analysis of individual categories of operations common to both general surgery residents and pediatric surgery fellows, these trends persisted; for inguinal and umbilical hernia repair, general surgery resident volume decreased (22.1 13 to 15.6 10; R2 ¼ 0.93) while pediatric fellow volume increased (90.5 17.6 to 104.4 20.7; R2 ¼ 0.34), albeit not along an even trend. Similar tendencies were found when evaluating repair of pyloric stenosis (resident, 3.9 3 to 2.8 3; R2 ¼ 0.60; fellow, 29.6 15 to 39.7 16.8; R2 ¼ 0.69) and repair of intestinal atresia or stenosis (resident, 1.3 2 to 1.1 2; R2 ¼ 0.34; fellow, 4.3 4 to 11.8 8; R2 ¼ 0.21). In the remaining categories considered for comparison, mean general surgery resident case volume remained low over time while pediatric surgery fellow volumes increased, with the exception of orchiopexy and open anti-reflux operations, for which both resident and fellow volumes decreased over time. The number of teaching cases in pediatric surgery decreased for both pediatric surgery fellows and general surgery residents. Although the percentage of general surgery resident teaching cases performed overall during the chief year fell modestly (28.8%), from 6.6% to 4.7% (R2 ¼ 0.53), median teaching cases over 5 years dropped by 77.0%, from 126 (29:309 [10th:90th percentiles]) to 29 (11:61 [10th:90th percentiles]). The median number of pediatric cases logged as teaching cases over this time period dropped from 2 (0:11 [10th:90th percentiles]) to zero (0:0 [10th:90th percentiles]) (R2 ¼ NA). For pediatric surgery fellows, the drop in teaching cases was similarly steep, with the mean declining 56.0%, (100.7 396 to 43.3 28; R2 ¼ 0.66) and the percentage of
pediatric surgery fellow operations logged as teaching cases decreasing 53.5%, from 10.3% to 4.8% (R2 ¼ 0.64) (Fig. 2). This trend was also present among the most frequently logged cases by pediatric surgery fellows, with the average number of teaching cases for inguinal and umbilical hernia repair decreasing 72.9% (9.6 8.4 to 2.6 1.7; R2 ¼ 0.55), and pyloric stenosis volume decreasing 79.3% (5.8 10 to 1.2 1; R2¼ 0.67). General surgery resident case log values were extremely low for advanced operations, such as those for meconium ileus or necrotizing enterocolitis (mean ¼ 0.36) and definitive repair of Hirschsprung’s disease or imperforate anus (mean ¼ 0.68). Pediatric surgery fellow case volume for these categories (meconium ileus or necrotizing enterocolitis: combined mean ¼ 29.2; and definitive repair of Hirschsprung’s disease or imperforate anus, combined mean ¼ 25.8) has remained high over time. The fraction of these cases performed as teaching cases, however, remained low: 0.8% 0.7% and 0.4% 0.6%, respectively. Resident participation as first assistants in pediatric surgery cases also remained low during the time period evaluated in this study. The median number of first assistant cases logged by general surgery residents fluctuated between 0 and 1 (0, 1.5) over time.
DISCUSSION As part of their progress toward graduation and independent practices, senior surgical residents classically became teachers to junior residents, under the supervision of attending surgeons and within the safety of a structured residency. Numerous factors have challenged this model of training, including duty hour restrictions, increased patient involvement in decision-making, development of day surgery units, productivity-based compensation
Category
1999 2000 2001 2002 2003 2004 2005
22.2 e
22.7 e
21.9 20.5 20.4 90.5 104 88.3
0.4 e
0.4 e
0.4 e
0.4 13.5
1.2 e
1.7 e
1.9 e
0.3 e
0.5 e
1.6 e
2008
2009
2010
18.6 99.8
18.6 84.9
18.6 104
0.4 0.3 12.9 13.3
0.4 12.5
0.4 13.4
0.4 13.3
0.4 13.4
0.3 13.6
1.8 25.4
1.7 1.4 22.1 20.6
1.4 17.2
1.1 17.2
1.1 16.2
1.1 15.9
0.6 e
0.8 23.5
0.9 0.9 25.8 28.5
1 25.6
1 23.4
1 29.7
1.6 e
1.5 e
1.4 4.3
1.1 8.8
1.1 9.6
1.2 8.6
3.8 e
4 e
4.1 e
4 29.6
3.7 3.5 32.5 34.6
3.7 37
1.3 e
1.5 e
1.5 e
1.5 14
1.6 1.5 17.3 20
0.5 e
0.4 e
0.4 e
0.4 12.9
0.8 e
0.7 e
0.8 e
1 e
1 e
1.8 e
0.8 e
39.8 e
41.1 e
2013
R2
16.7 109
15.6 0.9 104 0.3
0.3 13.5
0.3 13.5
0.3 0.6 13 0.1
1 13.5
0.9 11.1
0.7 10.6
0.6 0.4 7.4 1
1 28.1
0.9 30.2
1 25.4
1.1 26.6
1.1 0.8 26.5 0.1
1.2 10.5
1.2 9.4
1.1 8.6
1.1 6.9
1.1 11.2
1.1 0.6 11.8 0.2
3.9 38.9
3.9 36.2
3.8 42.1
3.5 39.4
3.2 40.6
3 39.2
2.8 0.6 39.7 0.7
1.5 18.2
1.5 20.6
1.5 20.8
1.5 18.3
1.4 18.3
1.2 19.4
1.2 18.1
1.1 0.1 18 0.1
0.4 0.4 29.8 32.5
0.3 36.2
0.3 33
0.3 35.3
0.3 32.2
0.3 27.1
0.3 28.1
0.3 27.8
0.3 0.7 26.3 0
0.8 51.5
0.7 0.7 23.5 24.8
0.7 21.3
0.6 23.1
0.6 25.2
0.7 23.6
0.6 22.9
0.6 22.5
0.6 23.4
0.6 0.7 22.5 0.3
1.1 e
1 6.5
1.1 1 19.2 18.9
1.1 21.8
1.1 20.6
1.1 23.3
1.1 21.7
1.1 21.5
1.1 20
1 21.9
1 0.1 18.6 0.3
1.8 e
1.6 26.2
1.6 1.4 18.5 17.9
1.5 28
1.4 16
1.4 21.5
1.4 19.7
1.3 17.4
1.3 18.4
1.3 16.4
1.3 0.2 18.9 0.2
1.3 10.8
41.8 39.8 36 e 980 983
17.6 16.5 109 111
2012
36.2 36.2 34.1 34.1 34.2 32 NR 1,021 1,002 1,116 1,149 1,126
30.7 30.4 29.1 0.9 NR 1,168 1,178 0.9
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19.9 105
2011
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NR, totals not recorded in database.
21.5 e
2007
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Herniorrhaphy (inguinal and umbilical) Resident 22.1 Fellow e Herniorrhaphy (diaphragmatic) Resident 0.5 Fellow e Anti-reflux operation (open) Resident 0.8 Fellow e Anti-reflux operation (laparoscopic) Resident 0.1 Fellow e Repair of intestinal atresia or stenosis Resident 1.3 Fellow e Repair of pyloric stenosis Resident 3.9 Fellow e Operation for malrotation or intussusception Resident 1.2 Fellow e Operation for meconium ileus or necrotizing enterocolitis Resident 0.6 Fellow e Definitive operation for Hirschsprung’s or imperforate anus Resident 0.8 Fellow e Repair omphalocele or gastroschisis Resident 1 Fellow e Orchiopexy Resident 1.7 Fellow e All pediatric cases Resident 39.7 Fellow e
2006
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Table 1. General Surgery Resident and Pediatric Surgery Fellow Case Volume by Operative Category (Means)
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strategies, and an increase in fellowship programs.8-10 With the increase in matriculation to specialty fellowships,4,11, there has been a vigorous debate over general surgery resident experience in these specialties, and the ability of a general surgery residency graduate to operate independently.3,5,8,12-15 Nowhere is this more prevalent than in the field of pediatric surgery, in which the demand for fellowship trained pediatric surgeons has blossomed over the past 2 decades. The ACGME database provides a unique opportunity to compare trends not only in resident and fellow overall case volume, but for many specific operation categories as well. Although past reports have shown an insignificant decrease in total case volume for general surgery residents over time,13,16-19 the ACGME database reveals a much different pattern with regard to pediatric surgery case volume. We observed a significant drop in both the average and total pediatric surgery operative experience of general surgery residents from 1999 to 2014. The most prevalent declines were seen in common operations, including herniorrhaphy, repair of pyloric stenosis, and operation for intestinal atresia or stenosis. These are all cases with which a rural surgeon ought to be familiar and might see in practice, yet almost 30% of graduates have not met the minimum number of pediatric cases required by the ACGME. This has occurred concurrently with an overall increase in the total and category-specific case volume reported by pediatric surgery fellows over time. It is difficult to identify a solitary explanation for this trend because it is most likely multifactorial. Gow and colleagues20 determined that the decline in operative volume began before the implementation of duty hour restrictions. It is often assumed that the presence of a fellowship within a department adversely affects the experience of surgery residents. The ACGME case logs do not stratify data according to the presence of fellows. However, Hanks and associates11 demonstrated that the presence of a fellowship is often associated with higher than average overall resident caseload and complex case exposure.11 Establishment of a pediatric surgery fellowship at Vanderbilt University resulted in an increase in the number of pediatric surgery attending physicians, overall case volume, surgery admissions, and relative value units. Nevertheless, the median pediatric surgery case volume among general surgery residents at Vanderbilt decreased from 34 to 23.5, with a case-specific decrease for herniorrhaphy from 12 to 6.5.4 This trend is consistent with our findings on a national scale, with an overall decline of 26.7% and a herniorrhaphy-specific drop of nearly 30%. General surgery resident participation in complex pediatric surgery cases has been consistently low, and
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understandably so. Fellows must have adequate experience with complex cases to train properly for their careers. The rise in minimally invasive pediatric surgery cases may also have contributed to the decline observed in resident experience.20,21 A survey of 331 pediatric surgeons revealed that most pediatric surgery attending surgeons reserve laparoscopic pyloromyotomy for fellows, while 45% of pediatric attending surgeons believe that general surgery residents should not at all be trained to perform pyloromyotomy.21 The role of first assistant, in which a resident has the opportunity to see and understand the complexities of an operation, has become lost over the past 2 decades. It has been suggested that duty hour restrictions have most negatively affected this particular resident role,22 although the increase in the involvement of physician extenders could allow for some resurgence of the “see one” step of the historical “see one, do one, teach one” model. Time spent in the operating room, even as a first assistant, is an important aspect of residency training. Without this role, residents rely heavily on simulation and educational materials, which cannot replicate the value of first-hand experience.3,5,7,22 With pediatric surgery fellows performing an increasing volume of both common and complex operations, there is a missed opportunity for residents to participate as first assistants. Although each of these developments is understandable, those pertaining to teaching cases were perhaps most striking. The decrease in teaching cases among pediatric surgery fellows was more than 50%. This decline was not exclusive to complex cases, with the average number of teaching cases for hernia repair dropping 81%, from 15.7 to 3.0. Similar to the overall case volume decrease, the reasons for declining teaching assistant cases are likely multifactorial, including resident duty hour restrictions, patient self-advocacy, and pervasive practices.3 Still, it would stand to reason that if fellows are performing increasing numbers of pediatric surgery operations, their ability and confidence in those operations should similarly improve. There continues to be a demand for fellowship-trained pediatric surgeons, which has coincided with an increasing number of positions in community children’s hospitals and pediatric specialty centers.23,24 New graduates of pediatric surgery fellowship programs have experienced an increase in average starting salaries, reflecting this demand.25 In light of these trends, it follows that fellows should gain further autonomy in training, where supervision and experience exist, in order to maximize the chances of success early in their clinical careers. If we can couple this autonomy with increased resident participation in these cases, then we enhance the experience
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Figure 2. Pediatric surgery fellow case volume (means: overall and teaching).
of those who may enter rural practice and may be called on to operate on pediatric patients. It is plausible that with this proper training, general surgeons in rural practice can achieve equivalent outcomes in the more common pediatric operations.26 Furthermore, we can reduce costs with appropriate care in the rural setting, both for states with large rural populations and for the patients and families themselves who must often coordinate and pay for long distance travel, lodging, and time off from work. In a population of often low economic status, these costs can be near prohibitive. There are several limitations to this study. These data are dependent on residents and fellows logging their cases appropriately. However, due to low numbers and the requirements of the ACGME, pediatric cases are often coveted by general surgery residents, and systematic, significant under-reporting is unlikely. It is also possible that residents or fellows are not accurately logging their teaching cases. However, the ACGME does not allow for 2 surgery residents to report the same operation on the same day, unless 1 is designated as a teaching assistant. In that both residents and fellows have relatively few teaching cases, they are also unlikely to be under-reported. Notably, first assistant cases may not be included among the required case volume, so these data must be interpreted carefully. In addition, the case log data available for pediatric surgery fellows begin in 2003, limiting some comparisons between groups. However, the resident data between 1999 and 2003 were used only to establish trends and are not extrapolated or compared with data from pediatric surgery fellows. Therefore, it is reasonable to include these data in order to better understand the overall trends. Lastly, there is a substantial number of nonspecified
cases recorded by surgery residents, defined as any operation performed on a patient under the age of 13. These data cannot be further interpreted beyond bare numbers.20 Overall, the analyzed data suggest that a unique opportunity exists to benefit the training of both general surgery residents and pediatric surgery fellows. With greater experience than in the past, fellows can assume roles as teaching assistants during their second year of training. This would not only benefit fellows, who would gain confidence and understanding while still under the supervision of attending surgeons, but it would enhance general surgery residents’ experience as well.13,14 By increasing the autonomy of one, we increase the exposure of the other. We should similarly encourage residents to participate in complex cases as first assistants, so they can better understand the pathology and physiology of the patients they will undoubtedly take care of during the remainder of the patients’ course. It may also behoove residency training programs to include a certain number of first assistant pediatric cases to be performed by general surgery residents as part of the minimum requirements for graduation. This would serve to broaden the exposure of residents to many operations they might not otherwise ever see. The increased use of, and even dependence on, physician extenders and midlevel providers offers another avenue by which to increase the amount of time residents are able to spend in the operating room, both as teaching assistants and as first assistants. The goal of adhering to duty hour restrictions should not simply be to minimize the amount of time residents spend on nonclinical work, but rather to maximize the amount of time the residents spend in the clinical and operating room settings.
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Invited Commentary
CONCLUSIONS We believe that there are a sufficient number of pediatric operations to permit general surgery resident participation in various capacities without compromising the training of pediatric surgeons. Facilitating this will require enhanced cooperation between pediatric surgery faculty and general surgery residency and pediatric surgery fellowship programs, but the benefit to all involved is intriguing, and the feasibility ought to be further investigated. Author Contributions Study conception and design: Talutis, Sachs Acquisition of data: Talutis, Sachs Analysis and interpretation of data: Talutis, McAneny, Chen, Doherty, Sachs Drafting of manuscript: Talutis, McAneny, Chen, Doherty, Sachs Critical revision: Talutis, McAneny, Chen, Doherty, Sachs REFERENCES 1. ACGME. Case Logs Statistical Reports. Chicago, IL. Available at: https://www.acgme.org/acgmeweb/tabid/274/DataCollectionSystems/ ResidentCaseLogSystem/CaseLogsStatisticalReports.aspx. Accessed September 27, 2015. 2. Lee SL, Sydorak RM, Applebaum H. Training general surgery residents in pediatric surgery: educational value vs time and cost. J Pediatr Surg 2009;44:164e168. 3. Sachs TE, Pawlik TM. See one, do one, and teach none: resident experience as a teaching assistant. J Surg Res 2015;195: 44e51. 4. Snyder RA, Phillips SE, Terhune KP. Impact of implementation of a pediatric surgery fellowship on general surgery operative volume. J Surg Educ 2012;69:753e758. 5. Bell RH. Why Johnny cannot operate. Surgery 2009;146: 533e542. 6. Fingeret AL, Stolar CJ, Cowles RA. Trends in operative experience of pediatric surgical residents in the United States and Canada. J Pediatr Surg 2013;48:88e94. 7. 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;156:385e393. 8. Hirschl RB. The making of a surgeon: 10,000 hours? J Pediatr Surg 2015;50:699e706. 9. Kazaure HS, Roman SA, Sosa JA. The resident as surgeon: an analysis of ACS-NSQIP. J Surg Res 2012;178:126e132. 10. Zeigler MM. Pediatric surgical training: an historic perspective, a formula for change. J Pediatr Surg 2004;39: 1159e1172. 11. Hanks JB, Ashley SW, Mahvi DM, et al. Feast or famine? The variable impact of coexisting fellowships on general surgery resident operative volumes. Ann Surg 2011;254: 476e483. 12. Bruce PJ, Helmer SD, Osland JS, Ammar AD. Operative volume in the new era: a comparison of resident operative volume before and after implementation of 8-hour workweek restrictions. J Surg Educ 2010;67:412e416.
13. Kairys JC, McGuire K, Crawford AG, Yeo CJ. Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? J Am Coll Surg 2008;206:804e811. 14. Kamine TH, Gondek S, Kent TS. Decrease in junior resident case volume after 2011 ACGME work hours. J Surg Educ 2014;71:e59ee63. 15. Pellegrini CA, Warshaw AL, Debas HT. Residency training in surgery in the 21st century: a new paradigm. Surgery 2004; 136:953e965. 16. Christmas AB, Brintzenhoff RA, Sing RF, et al. Resident work hour restrictions impact chief resident operative experience. Am Surg 2009;75:1065e1068. 17. Feanny MA, Scott BG, Mattox KL, Hirshberg A. Impact of the 80-hour workweek on resident emergency operative experience. Am J Surg 2005;190:947e949. 18. Sadaba JR, Urso S. Does the introduction of duty-hour restriction in the United States negatively affect the operative volume of surgical trainees? Interactive Cardiovasc Thorac Surg 2011; 13:316e319. 19. Scally CP, Reames BN, Teman NR, et al. Preserving operative volume in the setting of the 2011 ACGME duty hour regulations. J Surg Educ 2014;71:580e586. 20. Gow KW, Drake FT, Aarabi S, Waldhausen JH. The ACGME case log: general surgery resident experience in pediatric surgery. J Pediatr Surg 2013;48:1643e1649. 21. Cosper GH, Menon R, Hamann MS, Nakayama DK. Residency training in pyloromyotomy: a survey of 331 pediatric surgeons. J Pediatr Surg 2008;43:102e108. 22. Picarella EA, Simmons JD, Borman KR, et al. “Do one, teach one” the new paradigm in general surgery residency training. J Surg Educ 2011;68:126e129. 23. Geiger JD, Drongowski RA, Coran AG. The market for pediatric surgeons: an updated survey of recent graduates. J Pediatr Surg 2003;38:397e405. 24. Nakayama DK, Burd RS, Newman KD. Pediatric surgery workforce: supply and demand. J Pediatr Surg 2009;44:1677e1682. 25. Darves B. Physician shortages in the specialties taking a toll. Waltham, MA: New England Journal of Medicine. Available at: http://www.nejmcareercenter.org/article/physician-shortagesin-the-specialties-taking-a-toll. Accessed November 18, 2015. 26. Evans C, van Woerden HC. The effect of surgical training and hospital characteristics on patient outcomes after pediatric surgery: a systematic review. J Pediatr Surg 2011;46:2119e2121.
Invited Commentary Michael G Caty, New Haven, CT
MD, MMM, FACS
Creation of subspecialties of general surgery has resulted in surgeons with very focused training and experience in the care of anatomic areas and age groups. This has a disruptive effect on the training and practice of the general surgeon and provokes the existential question: what is a general surgeon?
MD, MPH, FACS,
The ACGME requires general surgery residents (GSR) to perform 20 pediatric surgery cases as part of the total 750 cases before graduation. STUDY DESIGN: We queried the ACGME General Surgery (1999 to 2014) and Pediatric Surgery (2003 to 2014) Case Logs for all pediatric operations performed during training. Means (SD) and medians (10th:90th percentiles) were compared, and R2 was calculated for all trends. RESULTS: The number of pediatric surgery fellows (PSF) increased 63% (23 to 39; R2 ¼ 0.82), while GSR numbers increased 12% (989 to 1,105; R2 ¼ 0.77). Total and average pediatric surgery case volume for GSR decreased from 39,309 to 32,156 (R2 ¼ 0.90) and 39.7 13 to 29.1 10 (R2 ¼ 0.91), respectively. Meanwhile, average PSF case volume increased from 980 208 to 1,137 202 (R2 ¼ 0.83). These trends persisted for inguinal/umbilical hernia (GSR 22.1 13 to 15.6 10; R2 ¼ 0.93; PSF 90.5 17.6 to 104.4 20.7; R2 ¼ 0.34), pyloric stenosis (GSR 3.9 3 to 2.8 3; R2 ¼ 0.60; PSF 29.6 15 to 39.7 16.8; R2 ¼ 0.69), and intestinal atresia (GSR 1.3 2 to 1.1 2; R2 ¼ 0.34; PSF 4.3 4 to 11.8 8; R2 ¼ 0.21). The mean number of GSR pediatric operations diminished for both junior (37.1 20 to 27.3 16; R2 ¼ 0.88) and chief (2.6 5 to 1.7 5; R2 ¼ 0.75) years. Teaching cases in pediatric surgery decreased at all levels. Although the percentage of GSR teaching cases performed during chief years fell modestly (6.6% to 4.7%; R2 ¼ 0.53), median teaching cases dropped from 2 (0:11 [10th:90th percentiles]) to zero (0:0 [10th:90th percentiles]). Mean PSF teaching cases declined (100.7 396 to 44.5 42; R2 ¼ 0.72), while the percentage of operations that were teaching cases decreased more sharply (10.3% to 3.5%; R2 ¼ 0.82). CONCLUSIONS: Total pediatric surgery cases and PSF operative volume have increased, while GSR operative volume has decreased. Opportunities may exist to increase resident participation while providing further teaching opportunities for GSR, improving the quality of both resident and fellow training. (J Am Coll Surg 2016;222:1082e1088. 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)
BACKGROUND:
The Accreditation Council for Graduate Medical Education (ACGME) has established criteria for graduation from general surgery residency programs, including target case volumes by categories, such as trauma, vascular, and Disclosure Information: Nothing to disclose. Presented at the 96th Annual Meeting of the New England Surgical Society, Newport, RI, September 2015. Received October 17, 2015; Revised November 19, 2015; Accepted November 19, 2015. From the Departments of Surgery, Boston Medical Center, Boston University School of Medicine (Talutis, McAneny, Doherty, Sachs) and Boston Children’s Hospital, Harvard Medical School (Chen), Boston, MA. Correspondence address: Teviah Sachs, MD, MPH, Department of Surgical Oncology, Boston Medical Center, 820 Harrison Ave, FGH Building - Suite 5007, Boston, MA 02118. email: [email protected]
ª 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
pediatrics.1-4 The ACGME currently requires that general surgery residents perform a minimum of 750 cases, of which 20 must be identified as pediatric surgery cases (defined as patients under the age of 13) before graduation. This is divided into subgroups of umbilical/inguinal herniorrhaphy (n ¼ 8), appendectomy (n ¼ 6), and unspecified cases (n ¼ 6).4 The ACGME similarly has established requirements for graduation from pediatric surgery fellowship. Fellows are required to log 800 major pediatric surgical cases as primary surgeon during the 2 years of fellowship, with at least 25 operative resections of tumors and 75 neonatal cases.1 Although minimum requirements for operative volume exist within both general surgery residency programs and
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pediatric surgery fellowship programs, there are no data that ensure competency based on these figures.5,6 Pediatric surgical education for residents varies greatly among residency programs and institutions, and it is often limited to a few months during the entire 5-year general surgery residency.2,4 Beyond operative requirements, residents are responsible for the diagnosis and management of pediatric surgery patients.4 Given the limited exposure of residents to this discipline, it is critical that residents receive optimal exposure, education, and experience during pediatric surgery rotations.2 This experience presumably ensures a minimum competency in pediatric surgery for graduating residents.1 Our previous reports of trends in operative experiences of general surgery residents over time have revealed decreases in the number of cases residents perform, overall and in the role of teaching resident.3,7 Little is known about the pediatric surgery experiences of graduating residents and fellows over time. We sought to evaluate trends in operative case volume for general surgery residents and pediatric surgery fellows to identify possible strategies to improve the education of both groups.
METHODS The ACGME general surgery and pediatric surgery databases are based on all operations reported by residents and fellows, respectively. The number of operations in each category (eg, pediatric, breast, endocrine, etc) is tabulated and stratified according to the resident’s operative role: surgeon chief (cases performed during chief year), surgeon junior (all cases performed during the preceding years in which the resident was the primary surgeon), and teaching assistant (cases in which a senior resident guides a junior resident through the case). The aggregate number of cases for all 5 years, excluding first assistant cases, comprises the “surgeon total,” which is essential for graduating residents to receive credit toward certification. There is an additional category for first assistant (cases in which a resident observes and assists when needed); however, this category does not count toward graduate requirements. Similar data are recorded for pediatric surgery fellows. The operative role of fellows is specifically categorized by type of operation and stratified into total surgeon and teaching assistant. The ACGME database provides means, standard deviations, medians, and stratified percentiles (10th, 30th, 50th, 70th, and 90th) for the operative categories. We queried the ACGME database for overall case volume as well as total and operation-specific pediatric surgery case volume of graduating chief residents between 1999 and 2014. Data for pediatric surgery fellows were also queried and were available from 2003 to 2014. Operation-specific volume was further analyzed for fellow
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cases that could be matched to those available for residents (ie, hernia repair, repair of pyloric stenosis, etc). Standard measures of operative volumes using mean and total case volumes were identified. For years during which total case volumes were not provided (2010 to 2014), estimates were calculated using the total number of residents and the mean case volume for a particular operation. Certain operative categories within pediatric surgery fellow data are divided into open and laparoscopic operations. For the purposes of comparison analysis to general surgery resident case volume, where no such categorization exists, these subcategories were combined and presented as totals for the categories of herniorrhaphy, repair of pyloric stenosis, operation for malrotation or intussusception, operation for meconium ileus or necrotizing enterocolitis, and definitive operation for Hirschsprung’s disease or imperforate anus. We further identified percentiles (10%, 50%, and 90%) for both pediatric surgery and total teaching case volumes for general surgery residents to evaluate trends in teaching cases over time. Both means (SD) and medians (10th:90th percentiles) are presented. Raw data are not available through the ACGME, precluding the application of certain statistical models. However, linear data trends were examined by assessing a goodness of fit model based on the means presented and reported as the value of R2 (range 0 to 1).
RESULTS From 1999 to 2014, the total number of general surgery residents increased 12% (989 to 1,105; R2 ¼ 0.77). Total general surgery case volume similarly increased 14% during this interval, from 955,858 to 1,085,331 cases (R2 ¼ 0.83); the average number of cases performed by general surgery residents remained stable (996.5 204 to 982.2 162 cases; R2 ¼ 0.09). During the same period of time, the total number of pediatric surgery cases performed by graduating chief residents declined 18.2%, from 39,309 to 32,156 (R2 ¼ 0.90). The average number of pediatric surgery cases performed by general surgery residents decreased by 26.7%, from 39.7 19 to 29.1 16 (R2 ¼ 0.91). This was evident both for cases recorded during junior resident (37.1 20 to 27.3 16; R2 ¼ 0.88) and chief resident years (2.6 5 to 1.7 5; R2 ¼ 0.75) (Fig. 1). Between 2003 and 2014, the number of pediatric surgery fellows increased by 63% (23 to 39; R2 ¼ 0.82). In addition, the average pediatric surgery fellow case volume during this interval increased by 16%, from 980 208 to 1,167 145 (R2 ¼ 0.87). Similarly, total cases performed by pediatric surgery fellows increased 49.3%, from 23,516 to 46,363 (R2 ¼ 0.90). The decreasing number of total and average pediatric surgery operations logged by general surgery residents
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Figure 1. Trends in pediatric surgery case volume over time (means: resident and fellow).
coincided with an increase in the total and average number of operations logged by pediatric surgery fellows (Table 1). In an analysis of individual categories of operations common to both general surgery residents and pediatric surgery fellows, these trends persisted; for inguinal and umbilical hernia repair, general surgery resident volume decreased (22.1 13 to 15.6 10; R2 ¼ 0.93) while pediatric fellow volume increased (90.5 17.6 to 104.4 20.7; R2 ¼ 0.34), albeit not along an even trend. Similar tendencies were found when evaluating repair of pyloric stenosis (resident, 3.9 3 to 2.8 3; R2 ¼ 0.60; fellow, 29.6 15 to 39.7 16.8; R2 ¼ 0.69) and repair of intestinal atresia or stenosis (resident, 1.3 2 to 1.1 2; R2 ¼ 0.34; fellow, 4.3 4 to 11.8 8; R2 ¼ 0.21). In the remaining categories considered for comparison, mean general surgery resident case volume remained low over time while pediatric surgery fellow volumes increased, with the exception of orchiopexy and open anti-reflux operations, for which both resident and fellow volumes decreased over time. The number of teaching cases in pediatric surgery decreased for both pediatric surgery fellows and general surgery residents. Although the percentage of general surgery resident teaching cases performed overall during the chief year fell modestly (28.8%), from 6.6% to 4.7% (R2 ¼ 0.53), median teaching cases over 5 years dropped by 77.0%, from 126 (29:309 [10th:90th percentiles]) to 29 (11:61 [10th:90th percentiles]). The median number of pediatric cases logged as teaching cases over this time period dropped from 2 (0:11 [10th:90th percentiles]) to zero (0:0 [10th:90th percentiles]) (R2 ¼ NA). For pediatric surgery fellows, the drop in teaching cases was similarly steep, with the mean declining 56.0%, (100.7 396 to 43.3 28; R2 ¼ 0.66) and the percentage of
pediatric surgery fellow operations logged as teaching cases decreasing 53.5%, from 10.3% to 4.8% (R2 ¼ 0.64) (Fig. 2). This trend was also present among the most frequently logged cases by pediatric surgery fellows, with the average number of teaching cases for inguinal and umbilical hernia repair decreasing 72.9% (9.6 8.4 to 2.6 1.7; R2 ¼ 0.55), and pyloric stenosis volume decreasing 79.3% (5.8 10 to 1.2 1; R2¼ 0.67). General surgery resident case log values were extremely low for advanced operations, such as those for meconium ileus or necrotizing enterocolitis (mean ¼ 0.36) and definitive repair of Hirschsprung’s disease or imperforate anus (mean ¼ 0.68). Pediatric surgery fellow case volume for these categories (meconium ileus or necrotizing enterocolitis: combined mean ¼ 29.2; and definitive repair of Hirschsprung’s disease or imperforate anus, combined mean ¼ 25.8) has remained high over time. The fraction of these cases performed as teaching cases, however, remained low: 0.8% 0.7% and 0.4% 0.6%, respectively. Resident participation as first assistants in pediatric surgery cases also remained low during the time period evaluated in this study. The median number of first assistant cases logged by general surgery residents fluctuated between 0 and 1 (0, 1.5) over time.
DISCUSSION As part of their progress toward graduation and independent practices, senior surgical residents classically became teachers to junior residents, under the supervision of attending surgeons and within the safety of a structured residency. Numerous factors have challenged this model of training, including duty hour restrictions, increased patient involvement in decision-making, development of day surgery units, productivity-based compensation
Category
1999 2000 2001 2002 2003 2004 2005
22.2 e
22.7 e
21.9 20.5 20.4 90.5 104 88.3
0.4 e
0.4 e
0.4 e
0.4 13.5
1.2 e
1.7 e
1.9 e
0.3 e
0.5 e
1.6 e
2008
2009
2010
18.6 99.8
18.6 84.9
18.6 104
0.4 0.3 12.9 13.3
0.4 12.5
0.4 13.4
0.4 13.3
0.4 13.4
0.3 13.6
1.8 25.4
1.7 1.4 22.1 20.6
1.4 17.2
1.1 17.2
1.1 16.2
1.1 15.9
0.6 e
0.8 23.5
0.9 0.9 25.8 28.5
1 25.6
1 23.4
1 29.7
1.6 e
1.5 e
1.4 4.3
1.1 8.8
1.1 9.6
1.2 8.6
3.8 e
4 e
4.1 e
4 29.6
3.7 3.5 32.5 34.6
3.7 37
1.3 e
1.5 e
1.5 e
1.5 14
1.6 1.5 17.3 20
0.5 e
0.4 e
0.4 e
0.4 12.9
0.8 e
0.7 e
0.8 e
1 e
1 e
1.8 e
0.8 e
39.8 e
41.1 e
2013
R2
16.7 109
15.6 0.9 104 0.3
0.3 13.5
0.3 13.5
0.3 0.6 13 0.1
1 13.5
0.9 11.1
0.7 10.6
0.6 0.4 7.4 1
1 28.1
0.9 30.2
1 25.4
1.1 26.6
1.1 0.8 26.5 0.1
1.2 10.5
1.2 9.4
1.1 8.6
1.1 6.9
1.1 11.2
1.1 0.6 11.8 0.2
3.9 38.9
3.9 36.2
3.8 42.1
3.5 39.4
3.2 40.6
3 39.2
2.8 0.6 39.7 0.7
1.5 18.2
1.5 20.6
1.5 20.8
1.5 18.3
1.4 18.3
1.2 19.4
1.2 18.1
1.1 0.1 18 0.1
0.4 0.4 29.8 32.5
0.3 36.2
0.3 33
0.3 35.3
0.3 32.2
0.3 27.1
0.3 28.1
0.3 27.8
0.3 0.7 26.3 0
0.8 51.5
0.7 0.7 23.5 24.8
0.7 21.3
0.6 23.1
0.6 25.2
0.7 23.6
0.6 22.9
0.6 22.5
0.6 23.4
0.6 0.7 22.5 0.3
1.1 e
1 6.5
1.1 1 19.2 18.9
1.1 21.8
1.1 20.6
1.1 23.3
1.1 21.7
1.1 21.5
1.1 20
1 21.9
1 0.1 18.6 0.3
1.8 e
1.6 26.2
1.6 1.4 18.5 17.9
1.5 28
1.4 16
1.4 21.5
1.4 19.7
1.3 17.4
1.3 18.4
1.3 16.4
1.3 0.2 18.9 0.2
1.3 10.8
41.8 39.8 36 e 980 983
17.6 16.5 109 111
2012
36.2 36.2 34.1 34.1 34.2 32 NR 1,021 1,002 1,116 1,149 1,126
30.7 30.4 29.1 0.9 NR 1,168 1,178 0.9
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19.9 105
2011
Trends in Pediatric Surgery Operative Volume
NR, totals not recorded in database.
21.5 e
2007
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Herniorrhaphy (inguinal and umbilical) Resident 22.1 Fellow e Herniorrhaphy (diaphragmatic) Resident 0.5 Fellow e Anti-reflux operation (open) Resident 0.8 Fellow e Anti-reflux operation (laparoscopic) Resident 0.1 Fellow e Repair of intestinal atresia or stenosis Resident 1.3 Fellow e Repair of pyloric stenosis Resident 3.9 Fellow e Operation for malrotation or intussusception Resident 1.2 Fellow e Operation for meconium ileus or necrotizing enterocolitis Resident 0.6 Fellow e Definitive operation for Hirschsprung’s or imperforate anus Resident 0.8 Fellow e Repair omphalocele or gastroschisis Resident 1 Fellow e Orchiopexy Resident 1.7 Fellow e All pediatric cases Resident 39.7 Fellow e
2006
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Table 1. General Surgery Resident and Pediatric Surgery Fellow Case Volume by Operative Category (Means)
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strategies, and an increase in fellowship programs.8-10 With the increase in matriculation to specialty fellowships,4,11, there has been a vigorous debate over general surgery resident experience in these specialties, and the ability of a general surgery residency graduate to operate independently.3,5,8,12-15 Nowhere is this more prevalent than in the field of pediatric surgery, in which the demand for fellowship trained pediatric surgeons has blossomed over the past 2 decades. The ACGME database provides a unique opportunity to compare trends not only in resident and fellow overall case volume, but for many specific operation categories as well. Although past reports have shown an insignificant decrease in total case volume for general surgery residents over time,13,16-19 the ACGME database reveals a much different pattern with regard to pediatric surgery case volume. We observed a significant drop in both the average and total pediatric surgery operative experience of general surgery residents from 1999 to 2014. The most prevalent declines were seen in common operations, including herniorrhaphy, repair of pyloric stenosis, and operation for intestinal atresia or stenosis. These are all cases with which a rural surgeon ought to be familiar and might see in practice, yet almost 30% of graduates have not met the minimum number of pediatric cases required by the ACGME. This has occurred concurrently with an overall increase in the total and category-specific case volume reported by pediatric surgery fellows over time. It is difficult to identify a solitary explanation for this trend because it is most likely multifactorial. Gow and colleagues20 determined that the decline in operative volume began before the implementation of duty hour restrictions. It is often assumed that the presence of a fellowship within a department adversely affects the experience of surgery residents. The ACGME case logs do not stratify data according to the presence of fellows. However, Hanks and associates11 demonstrated that the presence of a fellowship is often associated with higher than average overall resident caseload and complex case exposure.11 Establishment of a pediatric surgery fellowship at Vanderbilt University resulted in an increase in the number of pediatric surgery attending physicians, overall case volume, surgery admissions, and relative value units. Nevertheless, the median pediatric surgery case volume among general surgery residents at Vanderbilt decreased from 34 to 23.5, with a case-specific decrease for herniorrhaphy from 12 to 6.5.4 This trend is consistent with our findings on a national scale, with an overall decline of 26.7% and a herniorrhaphy-specific drop of nearly 30%. General surgery resident participation in complex pediatric surgery cases has been consistently low, and
J Am Coll Surg
understandably so. Fellows must have adequate experience with complex cases to train properly for their careers. The rise in minimally invasive pediatric surgery cases may also have contributed to the decline observed in resident experience.20,21 A survey of 331 pediatric surgeons revealed that most pediatric surgery attending surgeons reserve laparoscopic pyloromyotomy for fellows, while 45% of pediatric attending surgeons believe that general surgery residents should not at all be trained to perform pyloromyotomy.21 The role of first assistant, in which a resident has the opportunity to see and understand the complexities of an operation, has become lost over the past 2 decades. It has been suggested that duty hour restrictions have most negatively affected this particular resident role,22 although the increase in the involvement of physician extenders could allow for some resurgence of the “see one” step of the historical “see one, do one, teach one” model. Time spent in the operating room, even as a first assistant, is an important aspect of residency training. Without this role, residents rely heavily on simulation and educational materials, which cannot replicate the value of first-hand experience.3,5,7,22 With pediatric surgery fellows performing an increasing volume of both common and complex operations, there is a missed opportunity for residents to participate as first assistants. Although each of these developments is understandable, those pertaining to teaching cases were perhaps most striking. The decrease in teaching cases among pediatric surgery fellows was more than 50%. This decline was not exclusive to complex cases, with the average number of teaching cases for hernia repair dropping 81%, from 15.7 to 3.0. Similar to the overall case volume decrease, the reasons for declining teaching assistant cases are likely multifactorial, including resident duty hour restrictions, patient self-advocacy, and pervasive practices.3 Still, it would stand to reason that if fellows are performing increasing numbers of pediatric surgery operations, their ability and confidence in those operations should similarly improve. There continues to be a demand for fellowship-trained pediatric surgeons, which has coincided with an increasing number of positions in community children’s hospitals and pediatric specialty centers.23,24 New graduates of pediatric surgery fellowship programs have experienced an increase in average starting salaries, reflecting this demand.25 In light of these trends, it follows that fellows should gain further autonomy in training, where supervision and experience exist, in order to maximize the chances of success early in their clinical careers. If we can couple this autonomy with increased resident participation in these cases, then we enhance the experience
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Figure 2. Pediatric surgery fellow case volume (means: overall and teaching).
of those who may enter rural practice and may be called on to operate on pediatric patients. It is plausible that with this proper training, general surgeons in rural practice can achieve equivalent outcomes in the more common pediatric operations.26 Furthermore, we can reduce costs with appropriate care in the rural setting, both for states with large rural populations and for the patients and families themselves who must often coordinate and pay for long distance travel, lodging, and time off from work. In a population of often low economic status, these costs can be near prohibitive. There are several limitations to this study. These data are dependent on residents and fellows logging their cases appropriately. However, due to low numbers and the requirements of the ACGME, pediatric cases are often coveted by general surgery residents, and systematic, significant under-reporting is unlikely. It is also possible that residents or fellows are not accurately logging their teaching cases. However, the ACGME does not allow for 2 surgery residents to report the same operation on the same day, unless 1 is designated as a teaching assistant. In that both residents and fellows have relatively few teaching cases, they are also unlikely to be under-reported. Notably, first assistant cases may not be included among the required case volume, so these data must be interpreted carefully. In addition, the case log data available for pediatric surgery fellows begin in 2003, limiting some comparisons between groups. However, the resident data between 1999 and 2003 were used only to establish trends and are not extrapolated or compared with data from pediatric surgery fellows. Therefore, it is reasonable to include these data in order to better understand the overall trends. Lastly, there is a substantial number of nonspecified
cases recorded by surgery residents, defined as any operation performed on a patient under the age of 13. These data cannot be further interpreted beyond bare numbers.20 Overall, the analyzed data suggest that a unique opportunity exists to benefit the training of both general surgery residents and pediatric surgery fellows. With greater experience than in the past, fellows can assume roles as teaching assistants during their second year of training. This would not only benefit fellows, who would gain confidence and understanding while still under the supervision of attending surgeons, but it would enhance general surgery residents’ experience as well.13,14 By increasing the autonomy of one, we increase the exposure of the other. We should similarly encourage residents to participate in complex cases as first assistants, so they can better understand the pathology and physiology of the patients they will undoubtedly take care of during the remainder of the patients’ course. It may also behoove residency training programs to include a certain number of first assistant pediatric cases to be performed by general surgery residents as part of the minimum requirements for graduation. This would serve to broaden the exposure of residents to many operations they might not otherwise ever see. The increased use of, and even dependence on, physician extenders and midlevel providers offers another avenue by which to increase the amount of time residents are able to spend in the operating room, both as teaching assistants and as first assistants. The goal of adhering to duty hour restrictions should not simply be to minimize the amount of time residents spend on nonclinical work, but rather to maximize the amount of time the residents spend in the clinical and operating room settings.
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Invited Commentary
CONCLUSIONS We believe that there are a sufficient number of pediatric operations to permit general surgery resident participation in various capacities without compromising the training of pediatric surgeons. Facilitating this will require enhanced cooperation between pediatric surgery faculty and general surgery residency and pediatric surgery fellowship programs, but the benefit to all involved is intriguing, and the feasibility ought to be further investigated. Author Contributions Study conception and design: Talutis, Sachs Acquisition of data: Talutis, Sachs Analysis and interpretation of data: Talutis, McAneny, Chen, Doherty, Sachs Drafting of manuscript: Talutis, McAneny, Chen, Doherty, Sachs Critical revision: Talutis, McAneny, Chen, Doherty, Sachs REFERENCES 1. ACGME. Case Logs Statistical Reports. Chicago, IL. Available at: https://www.acgme.org/acgmeweb/tabid/274/DataCollectionSystems/ ResidentCaseLogSystem/CaseLogsStatisticalReports.aspx. Accessed September 27, 2015. 2. Lee SL, Sydorak RM, Applebaum H. Training general surgery residents in pediatric surgery: educational value vs time and cost. J Pediatr Surg 2009;44:164e168. 3. Sachs TE, Pawlik TM. See one, do one, and teach none: resident experience as a teaching assistant. J Surg Res 2015;195: 44e51. 4. Snyder RA, Phillips SE, Terhune KP. Impact of implementation of a pediatric surgery fellowship on general surgery operative volume. J Surg Educ 2012;69:753e758. 5. Bell RH. Why Johnny cannot operate. Surgery 2009;146: 533e542. 6. Fingeret AL, Stolar CJ, Cowles RA. Trends in operative experience of pediatric surgical residents in the United States and Canada. J Pediatr Surg 2013;48:88e94. 7. 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;156:385e393. 8. Hirschl RB. The making of a surgeon: 10,000 hours? J Pediatr Surg 2015;50:699e706. 9. Kazaure HS, Roman SA, Sosa JA. The resident as surgeon: an analysis of ACS-NSQIP. J Surg Res 2012;178:126e132. 10. Zeigler MM. Pediatric surgical training: an historic perspective, a formula for change. J Pediatr Surg 2004;39: 1159e1172. 11. Hanks JB, Ashley SW, Mahvi DM, et al. Feast or famine? The variable impact of coexisting fellowships on general surgery resident operative volumes. Ann Surg 2011;254: 476e483. 12. Bruce PJ, Helmer SD, Osland JS, Ammar AD. Operative volume in the new era: a comparison of resident operative volume before and after implementation of 8-hour workweek restrictions. J Surg Educ 2010;67:412e416.
13. Kairys JC, McGuire K, Crawford AG, Yeo CJ. Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? J Am Coll Surg 2008;206:804e811. 14. Kamine TH, Gondek S, Kent TS. Decrease in junior resident case volume after 2011 ACGME work hours. J Surg Educ 2014;71:e59ee63. 15. Pellegrini CA, Warshaw AL, Debas HT. Residency training in surgery in the 21st century: a new paradigm. Surgery 2004; 136:953e965. 16. Christmas AB, Brintzenhoff RA, Sing RF, et al. Resident work hour restrictions impact chief resident operative experience. Am Surg 2009;75:1065e1068. 17. Feanny MA, Scott BG, Mattox KL, Hirshberg A. Impact of the 80-hour workweek on resident emergency operative experience. Am J Surg 2005;190:947e949. 18. Sadaba JR, Urso S. Does the introduction of duty-hour restriction in the United States negatively affect the operative volume of surgical trainees? Interactive Cardiovasc Thorac Surg 2011; 13:316e319. 19. Scally CP, Reames BN, Teman NR, et al. Preserving operative volume in the setting of the 2011 ACGME duty hour regulations. J Surg Educ 2014;71:580e586. 20. Gow KW, Drake FT, Aarabi S, Waldhausen JH. The ACGME case log: general surgery resident experience in pediatric surgery. J Pediatr Surg 2013;48:1643e1649. 21. Cosper GH, Menon R, Hamann MS, Nakayama DK. Residency training in pyloromyotomy: a survey of 331 pediatric surgeons. J Pediatr Surg 2008;43:102e108. 22. Picarella EA, Simmons JD, Borman KR, et al. “Do one, teach one” the new paradigm in general surgery residency training. J Surg Educ 2011;68:126e129. 23. Geiger JD, Drongowski RA, Coran AG. The market for pediatric surgeons: an updated survey of recent graduates. J Pediatr Surg 2003;38:397e405. 24. Nakayama DK, Burd RS, Newman KD. Pediatric surgery workforce: supply and demand. J Pediatr Surg 2009;44:1677e1682. 25. Darves B. Physician shortages in the specialties taking a toll. Waltham, MA: New England Journal of Medicine. Available at: http://www.nejmcareercenter.org/article/physician-shortagesin-the-specialties-taking-a-toll. Accessed November 18, 2015. 26. Evans C, van Woerden HC. The effect of surgical training and hospital characteristics on patient outcomes after pediatric surgery: a systematic review. J Pediatr Surg 2011;46:2119e2121.
Invited Commentary Michael G Caty, New Haven, CT
MD, MMM, FACS
Creation of subspecialties of general surgery has resulted in surgeons with very focused training and experience in the care of anatomic areas and age groups. This has a disruptive effect on the training and practice of the general surgeon and provokes the existential question: what is a general surgeon?