Sunday, December 11, 2016

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.


Anonymous said...

Might be why they are complaining when they get out they don't have enough experience?

Skeptical Scalpel said...

Yes, that in fact was my point.

Anonymous said...

Anonymous Europe: As a resident in training, what I wish for my training is to be able to perform as many operations a day as possible (best thing is to go home totally wasted at 18.00 hrs after performing at least 5-6 operations).

If someone from my generation wants to become a surgeon we do not sign up for:1. medical coding/needless-mindless paperwork, 2. pipetting in a lab, 3. doing statistics, 4. performing research. 5. Doing teaching in our free time/preparing for lectures. These things suck and are boring (at least for me).
We sign up for: 1. performing operations 2. doing pre- and post op care and follow up.
I might sound a bit milennial, and I do not mean to offend anyone, but I thought I would just speak what's on the mind of a lot of milennial surgical trainees.
The way I see it surgery is a bit like driving: If you have to drive 80 miles every day from one city to another regardless of snowstorms/ floods, whatever, you will eventually learn how to drive after a certain time, which varies from person to person.
If you drive only when the sun is shining or the roads are clear, you will only think you know how to drive...

Skeptical Scalpel said...

Thanks for the comment. Statistics can be fun and you need to know about it so you can properly evaluate papers you read in journals.

Kevin said...

Long time reader, first time poster. I'm the chief resident in a small program at a county type hospital. I find it fascinating that people are studying this topic. My personal bias is that many programs are clinically very busy with high volume of cases however often times the resident is relegated to a permanent first assistant role. How is this resident supposed to achieve their minimums, let alone become a safe, competent, independent surgeon? I'm sure many residents will log this type of experience as surgeon jr or surgeon chief, inflating their numbers and diluting their experience. Despite the shortcomings of my program (many), I am very grateful for my clinical experience so far such as opportunities to operate independently and take junior residents through cases. It doesn't seem like other are as fortunate

Skeptical Scalpel said...

Kevin, thank you for commenting. I agree with what you said. You are fortunate to be able to do cases independently and take junior residents through cases. If you can teach someone else how to do a case properly, you certainly know how to do it yourself.

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