Some general surgery residency graduates may not be competent to operate

A new study says 84% of general surgery residents in their last six months of training were rated as competent to perform the five most common general surgery core procedures—appendectomy, cholecystectomy, ventral hernia repair, groin hernia repair, and partial colectomy. However the percentage of those judged competent varied from a high of 96% for appendectomy to a low of 71% for partial colectomy.

When analyzing the other 127 core operations of general surgery, the investigators found that 26% of residents in their last six months of training were felt to not be competent to perform at least some of those procedures.

The study was presented at the annual meeting of the American Surgical Association in April 2017 and reported in ACS Surgery News.

Data were compiled from ratings of 522 residents by 437 faculty yielding 8526 different observations.

For all of the procedures rated, maximum resident autonomy was observed for 33% of cases, and the more complex the case, the less ready the residents were to perform it on their own.

The lead author of the study, Dr. Brian George of the University of Michigan, was asked whether the duration of surgery training should be increased. He answered, “The 20,000 hours of surgical residency should be enough to train a general surgeon to competence—it's up to us to figure out how.”

Who really did the case?

According to the Residency Review Committee for Surgery, "A resident may be considered the surgeon only when he or she can document a significant role in the following aspects of management: determination or confirmation of the diagnosis, provision of preoperative care, selection, and accomplishment of the appropriate operative procedure, and direction of the postoperative care."

In nearly all instances, resident "determination or confirmation of the diagnosis, provision of preoperative care, selection of the operative procedure, and direction of the postoperative care" happen only in emergencies. For the majority of elective patients and same day operations, the residents do not play significant roles in most components of perioperative management.

What about "accomplishment of the appropriate operative procedure"? Are the residents really doing the cases they scrub on?

A recent paper from the University of Texas Medical Branch in Galveston, called "Who did the case? Perceptions on resident operative participation," looked at this question in a surprisingly candid way. The authors asked residents and faculty to independently assess what percentage of the operation the resident performed.

For the 87 cases for which responses from both resident and attending surgeon were available, agreement on percent of the case performed by resident (< 25%, 25 to 50%, 50 to 75%, > 75%) occurred in 61%, agreement of the role the resident played (first assistant, surgeon junior year, surgeon chief resident, teaching assistant) occurred 63% of the time, and agreement on both percent and role occurred only 47% of the time.

This reminds me of a story from when I was a resident. In the surgeons' locker room one day, someone asked a senior attending if the resident who scrubbed with him had done the case. The attending replied, "He thinks he did."

That's what the authors from Texas found too. In about two-thirds of the cases with disagreement about the percent of a case the residents did, the residents felt they performed larger portions of the case than did the faculty.

What constitutes "a significant role" is open to interpretation.

A resident once came to me and said, "I'm not really sure I should claim I was the surgeon for a case I scrubbed on today. Should I log myself as 'surgeon' anyway?"

I said, "If you have to ask, you probably shouldn't claim it."

Surgical residents are supposed to enter the cases they do in an online database, and the RRC uses these data in its accreditation process. The American Board of Surgery mandates that residents perform specific numbers of various types of cases in order to be eligible to take their boards.

A 2016 study in the Journal of Surgical Education surveyed 82 residents from various surgical specialties at UC Irvine and found only about half of the responding residents were told how to assess what their role was, and they were often delinquent [for more than one year at times] in logging their procedures leading to inaccuracies in the logs.

The authors concluded that the way cases were being logged raised "concerns about the use of the system for assessing surgical preparedness or crediting training programs."

The two papers cited above are small studies from single institutions, but in my opinion, probably reflect the reality in most residency training programs.

Submitted case log numbers may be misleading. This may be a previously unidentified factor in the crisis in confidence afflicting some graduating chief surgical residents.

Would competency-based training be better? The buzz about competency-based training has died down, and there are skeptics including the authors of this thoughtful editorial from the Journal of Graduate Medical Education.

Starting in the 2017-2018 academic year, the American Board of Surgery will require a minimum of 850 operative procedures for the five-year training period and 200 operations in the chief resident year—increases from 750 and 150, respectively.

Will competency-based training or increasing the number of operations required help?

Not if the residents aren't really doing the cases.