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Original Investigation | Pacific Coast Surgical Association

The General Surgery Chief Resident Operative Experience:  23 Years of National ACGME Case Logs

Frederick Thurston Drake, MD1; Karen D. Horvath, MD1; Adam B. Goldin, MD, MPH2; Kenneth W. Gow, MD2
[+] Author Affiliations
1Department of Surgery, University of Washington Medical Center, Seattle
2Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Washington
JAMA Surg. 2013;148(9):841-847. doi:10.1001/jamasurg.2013.2919.
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Published online

Importance  The chief resident (CR) year is a pivotal experience in surgical training. Changes in case volume and diversity may impact the educational quality of this important year.

Objective  To evaluate changes in operative experience for general surgery CRs.

Design, Setting, and Participants  Review of Accreditation Council for Graduate Medical Education case logs from 1989-1990 through 2011-2012 divided into 5 periods. Graduates in period 3 were the last to train with unrestricted work hours; those in period 4 were part of a transition period and trained under both systems; and those in period 5 trained fully under the 80-hour work week. Diversity of cases was assessed based on Accreditation Council for Graduate Medical Education defined categories.

Main Outcomes and Measures  Total cases and defined categories were evaluated for changes over time.

Results  The average total CR case numbers have fallen (271 in period 1 vs 242 in period 5, P < .001). Total CR cases dropped to their lowest following implementation of the 80-hour work week (236 cases), but rebounded in period 5. The percentage of residents’ 5-year operative experience performed as CRs has decreased (30% in period 1 vs 25.6% in period 5, P < .001). Regarding case mix: thoracic, trauma, and vascular cases declined steadily, while alimentary and intra-abdominal operations increased. Recent graduates averaged 80 alimentary and 78 intra-abdominal procedures during their CR years. Compared with period 1, in which these 2 categories represented 47.1% of CR experience, in period 5, they represented 65.2% (P < .001). Endocrine experience has been relatively unchanged.

Conclusions and Relevance  Total CR cases declined especially acutely following implementation of the 80-hour work week but have since rebounded. Chief resident cases contribute less to overall experience, although this proportion stabilized before the 80-hour work week. Case mix has narrowed, with significant increases in alimentary and intra-abdominal cases. Broad-based general surgery training may be jeopardized by reduced case diversity. Chief resident cases are crucial in surgical training and educators should consider these findings as surgical training evolves.

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Figure 1.
Total Major Cases per Graduating Resident

No standard deviations are available for academic years 2004-2005 and 2005-2006 because of changes in the Accreditation Council for Graduate Medical Education reports. The vertical dotted black line distinguishes the training era prior to duty-hour restrictions from the training era after implementation of duty-hour restrictions. The bars indicate standard deviations.

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Figure 2.
Number of Cases by Period

Mean total major cases (A) and total chief resident cases (B) by period. Period delineations are described in the text. Asterisks (*) denote significant changes in mean case numbers compared with the immediately previous period (analysis of variance with Bonferroni adjustment for multiple comparisons). For total major cases, period 3 and period 5 are not significantly different. The bars indicate standard deviation.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Total Chief Resident Cases per Graduating Resident

No standard deviations are available for academic years 2004-2005 and 2005-2006 because of changes in the Accreditation Council for Graduate Medical Education reports. The vertical dotted black line distinguishes the training era prior to duty-hour restrictions from the training era after implementation of duty-hour restrictions. The bars indicate standard deviation.

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