Are General Surgery Residencies Preparing Graduates for the Practice of Today's General Surgeon? An Analysis of American Board of Surgery Data From Applicants and Re-certifying Surgeons.

OBJECTIVE: To compare the operative experience of general surgery residents and practicing general surgeons. SUMMARY OF BACKGROUND DATA: The scope of general surgery has evolved, yet it remains unknown whether residents are being exposed to the right mix of operations during residency. METHODS: A retrospective review of operative case logs submitted to the American Board of Surgery by US general surgery graduates and practicing general surgeons from 2013 to 2017 was performed. The operative experience of both cohorts was calculated as a proportion of total experience and ranked by frequency. The proportional experience between cohorts was analyzed using factorial analysis of variance. RESULTS: During the 5-year period, 5482 graduates applied for initial American Board of Surgery certification, and 4152 diplomates applied for recertification. Among all operative domains, the graduate experience was similar to that of diplomates in 6 of 12 areas (abdomen, alimentary tract, endoscopy, endocrine, other, skin/soft tissue; all P > 0.05). Residents have a greater experience in subspecialty areas (pediatric, thoracic, trauma, vascular, and plastic) at the expense of fewer breast procedures (all P < 0.05). The 30 operations most commonly performed by graduates comprised 67% of their total operative experience. Among these, residents performed 25 cases ≥10 times, 14 cases ≥20 times, and 7 cases ≥40 times. CONCLUSIONS: The operative experience of graduating US general surgery residents is largely similar to that of practicing general surgeons, particularly for core general surgery domains. These data offer reassurance that surgical training in the modern era appropriately exposes residents to the operations they may perform in practice.

Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training.

BACKGROUND: Physicians, particularly trainees and those in surgical subspecialties, are at risk for burnout. Mistreatment (i.e., discrimination, verbal or physical abuse, and sexual harassment) may contribute to burnout and suicidal thoughts. METHODS: A cross-sectional national survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination assessed mistreatment, burnout (evaluated with the use of the modified Maslach Burnout Inventory), and suicidal thoughts during the past year. We used multivariable logistic-regression models to assess the association of mistreatment with burnout and suicidal thoughts. The survey asked residents to report their gender. RESULTS: Among 7409 residents (99.3% of the eligible residents) from all 262 surgical residency programs, 31.9% reported discrimination based on their self-identified gender, 16.6% reported racial discrimination, 30.3% reported verbal or physical abuse (or both), and 10.3% reported sexual harassment. Rates of all mistreatment measures were higher among women; 65.1% of the women reported gender discrimination and 19.9% reported sexual harassment. Patients and patients' families were the most frequent sources of gender discrimination (as reported by 43.6% of residents) and racial discrimination (47.4%), whereas attending surgeons were the most frequent sources of sexual harassment (27.2%) and abuse (51.9%). Proportion of residents reporting mistreatment varied considerably among residency programs (e.g., ranging from 0 to 66.7% for verbal abuse). Weekly burnout symptoms were reported by 38.5% of residents, and 4.5% reported having had suicidal thoughts during the past year. Residents who reported exposure to discrimination, abuse, or harassment at least a few times per month were more likely than residents with no reported mistreatment exposures to have symptoms of burnout (odds ratio, 2.94; 95% confidence interval [CI], 2.58 to 3.36) and suicidal thoughts (odds ratio, 3.07; 95% CI, 2.25 to 4.19). Although models that were not adjusted for mistreatment showed that women were more likely than men to report burnout symptoms (42.4% vs. 35.9%; odds ratio, 1.33; 95% CI, 1.20 to 1.48), the difference was no longer evident after the models were adjusted for mistreatment (odds ratio, 0.90; 95% CI, 0.80 to 1.00). CONCLUSIONS: Mistreatment occurs frequently among general surgery residents, especially women, and is associated with burnout and suicidal thoughts.

An Empirical National Assessment of the Learning Environment and Factors Associated With Program Culture.

OBJECTIVES: To empirically describe surgical residency program culture and assess program characteristics associated with program culture. SUMMARY BACKGROUND DATA: Despite concerns about the impact of the learning environment on trainees, empirical data have not been available to examine and compare program-level differences in residency culture. METHODS: Following the 2018 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. Survey items were analyzed using principal component analysis to derive composite measures of program culture. Associations between program characteristics and composite measures of culture were assessed. RESULTS: Analysis included 7387 residents at 260 training programs (99.3% response rate). Principal component analysis suggested that program culture may be described by 2 components: Wellness and Negative Exposures. Twenty-six programs (10.0%) were in the worst quartile for both Wellness and Negative Exposure components. These programs had significantly higher rates of duty hour violations (23.3% vs 11.1%), verbal/physical abuse (41.6% vs 28.6%), gender discrimination (78.7% vs 64.5%), sexual harassment (30.8% vs 16.7%), burnout (54.9% vs 35.0%), and thoughts of attrition (21.6% vs 10.8%; all P < 0.001). Being in the worst quartile of both components was associated with percentage of female residents in the program (P = 0.011), but not program location, academic affiliation, size, or faculty demographics. CONCLUSIONS: Residency culture was characterized by poor resident wellness and frequent negative exposures and was generally not associated with structural program characteristics. Additional qualitative and quantitative studies are needed to explore unmeasured local social dynamics that may underlie measured differences in program culture.

Declining Resident Experience in Open Vascular Operations Threatens the Status of Vascular Surgery as an Essential Content Area of General Surgery Training.

OBJECTIVE: The objective of this study was to document trends in the performance of open arterial vascular surgery procedures (OAVP) by general surgery residents (GSR). BACKGROUND: The ACGME Review Committee for Surgery considers vascular surgery (VS) to be an "essential content area." However, the operative experience in VS for GSRs is threatened by 1) increasing numbers of GSRs, 2) increasing numbers of VS trainees, and 3) the proliferation of endovascular surgery. METHODS: The last 16 years of ACGME national reports of case logs for completing GSRs were reviewed. Total vascular operations and OAVPs performed as "surgeon" were recorded and analyzed. The number of individuals completing ACGME programs in general and vascular surgery annually over that period were also recorded and analyzed. To better understand long-term and more recent trends, trends were analyzed for the 15-year period spanned by the 16 years of data as well as the most recent 10- and 5-year periods. RESULTS: The number of individuals completing both general and vascular surgery programs increased significantly. Over 15 years, the total vascular operations performed by GSRs significantly declined as did the total OAVPs and the OAVPs in 7 of 9 categories. In just the last 5 years, significant declines occurred in 5 OAVP categories. CONCLUSIONS: Operative experience in OAVPs for GSRs has significantly declined. Because fundamental VS skills are necessary for operative general surgery, VS should remain an essential content area. However, programs cannot solely depend on operative experience to teach fundamental VS skills.

Update on Outcomes of a Novel Pathway for Thoracic Surgery Training.

BACKGROUND: The Joint Surgery-Thoracic Surgery (JS-TS) pathway began as a pilot program to grant both general surgery (GS) residency and thoracic surgery (TS) fellowship credit for 12 months of the PGY-4 and 5 years. This review updates the outcomes of this novel program. STUDY DESIGN: GS and TS programs in all approved JS-TS institutions were contacted for data collection, including JS-TS enrollee demographics and GS and TS case logs (CLs). National GS and TS CL data, and program and institutional data were publicly available. Enrollee case numbers were compared with those of their contemporaries. The American Board of Surgery and American Board of Thoracic Surgery provided certification data. Only enrollees who completed GS through 2019 were included. RESULTS: There were 90 JS-TS enrollees in 14 institutions. Two enrollees withdrew and 1 had not completed TS at the time of data collection leaving 87 for analysis. GS CLs were available for all 87 enrollees. TS CLs were available for all 62 enrollees who completed fellowship in 2016 or later. In GS, enrollees recorded fewer cases than their contemporary PGY-5s nationally in all domains except thoracic and endocrine. In TS, mean enrollee case numbers exceeded those of national contemporaries in every major category. Sixty-two JS-TS enrollees have achieved American Board of Surgery certification. Eighty-two enrollees are American Board of Thoracic Surgery certified with 5 currently in the certification process. CONCLUSIONS: The JS-TS pathway has proven a successful alternative route for TS training and could be a blueprint for other specialties considering novel avenues to specialty training.

Trends in pancreatic surgery experience in general surgery residency in the US, 1990-2021.

BACKGROUND: We hypothesized a decline in resident pancreatic operative experience. The study assesses trends in that experience since 1990. METHODS: Accreditation Council for Graduate Medical Education (ACGME) national case log data of general surgery residency graduates from 1990 to 2021 were reviewed. Collected and analyzed were the mean and median total number of pancreatic operations per resident, the mean number of specific case types performed, and the annual number of residency graduates. For selected procedures, the mean number of cases by resident role (Surgeon-Chief and Surgeon-Junior) was also analyzed. RESULTS: Both the mean and median total number of resident pancreatic operations has declined since 2009 as have the mean number of several specific pancreatic case types, including resections. The annual number of residency graduates has significantly increased since 1990, and particularly since 2009. CONCLUSIONS: Resident volume in pancreatic operations has significantly declined over the last decade.

Outcomes of the Early Specialization Program in Vascular Operation.

BACKGROUND: The Early Specialization Program (ESP) in vascular surgery (VS) began as a "pilot program" in 2003. There is only one published report on ESP outcomes. STUDY DESIGN: The general surgery (GS) and VS programs of all institutions using the ESP were contacted. Data gathered included demographics of ESP enrollees, participants' case logs (CLs), and CLs of participants' residency graduating classmates. National CLs, program and institutional data, and participants' certification status were publicly available. RESULTS: Nine institutions have enrolled 34 participants. Four withdrew, and four are in the GS component. Of 26 who have completed ESP, residency CLs were available for 20. Participants' percentile rankings among national contemporaries were lower than 13th for surgeon-junior cases (SJCs), higher than 73rd for surgeon-chief cases (SCCs), and 49th for total major cases (TMCs). They were lower than the 40th percentile in all domains except operative trauma (52; SD 23.8) and vascular (84.7; SD 22.1). As a percentage of the mean (% mean) for their own graduating classes, participants performed 91.8% (SD 16.5) as many SJCs, 143.7% (SD 45.1) as many SCCs, and 105% (SD 11.4) as many TMCs. Participants performed more than 79 % mean in every domain, including 213.4% (SD 82.4) as many vascular cases. As fellows, they ranked higher than the 50th percentile nationally in all but two categories. Twenty-four of 26 certified in GS. GS certification has lapsed for 5, 17 remain initially certified, and 2 have re-certified. All have current VS certification. CONCLUSION: Although infrequently employed, ESP remains an effective option for those who seek both GS and VS certification.

Contemporary Practice of General Surgery in the US: Analysis of American Board of Surgery Diplomate Case Logs.

BACKGROUND: The demographics and operative experience of general surgeons certified by the American Board of Surgery were last examined a decade ago. This study examines the contemporary workforce and scope of practice of general surgeons. STUDY DESIGN: Applications of diplomates seeking American Board of Surgery recertification from 2013 to 2017 were reviewed. Demographic data and case logs from the year before submission were analyzed. Total operative volume was examined, as were total volumes for 13 operative domains and 11 abdominal and alimentary tract subdomains. RESULTS: There were 4,735 general surgeons certified by the American Board of Surgery with a mean ± SD age of 53 ± 8 years and included 19% women and 14% international graduates. Regions of practice were 22% Northeast, 31% Southeast, 20% Midwest, 20% West, and 7% Southwest. Practice settings were 86% urban, 9% large rural, 4% small rural, and 1% isolated. Forty-one percent were 10 years, 35% were 20 years, and 24% were 30 years since initial certification. On average, general surgeons performed 417 ± 338 procedures per year, with abdominal, alimentary tract, and endoscopy being the most common. On multivariable analysis, male sex and being midcareer or late career were positively associated with being a high-volume (top quartile) surgeon, whereas age and practicing in either the Northeast or West demonstrated a negative association. CONCLUSIONS: The demographics of general surgeons have remained stable over time, except for an increased proportion of female surgeons. The overall operative experience is similar to years past but is widely variable between surgeons. Periodic analysis of these data is important for education and certification purposes.

The History of Surgical Education in the United States: Past, Present, and Future.

In just over 100 years, surgical education in the United States has evolved from a disorganized practice to a refined system esteemed worldwide as one of the premier models for the training of physicians and surgeons. But in the changing environment of health care, new challenges have arisen that could warrant a reform. To design our future, we must understand our past. The present work is not intended to be a comprehensive account of the history of American surgery. Instead, it tells the abridged history of surgical education in our country: the evolution from apprenticeships to residencies; the birth of hospital-based teaching; the impact of key historical events on training; the marks left by some preeminent characters; the conception of regulatory entities that steer our education; and, finally, how our process of training surgeons might need to be refined for the continued progress of our profession. Told in chronological order in a manner that will be memorable to readers, this story weaves together the key events that explain how our current surgical training models came to be. We conclude with a timely invitation to draw from these past lessons to redesign the future of graduate medical education, making a case for the transition to time-variable, competency-based medical education for surgical residency programs in America.

Impact of Integrated Thoracic Residency on General Surgery Residents' Thoracic Operative Volume.

BACKGROUND: Integrated thoracic surgery (I-6) programs have become popular over traditional general surgery (GS) pathways since their inception in 2007. However the effect of I-6 programs on GS resident training remains unknown. The purpose of this study was to evaluate the effect of I-6 programs on the thoracic operative experience of co-located GS residents. METHODS: Thoracic surgery cases recorded by residents in GS programs co-located with I-6 programs until 2019 were analyzed. Cases were reviewed 5 years before (TSR-5) through 5 years after (TSR-5) the matriculation of the first thoracic resident in the co-located I-6 program. To contextualize the overall trends in the field Accreditation Council for Graduate Medical Education GS resident case logs from 1990 to 2018 were analyzed and total thoracic surgery cases recorded. Statistical analysis was performed with linear regression. RESULTS: Residents in 19 GS programs with co-located I-6 programs showed an increase in total thoracic cases from 3710 to 4451 (Δ/year of +85.05 cases a year; P = .03) balanced by an increase in GS residents from 107 to 126 (Δ/year of +1.45; P = .01) with no significant overall change in the median thoracic operative case volume (31.00 at both thoracic residency before and after 5 years). Nationally from 1990 to 2018 there was no change in the total thoracic operative experience for GS graduates. CONCLUSIONS: The introduction of I-6 programs did not negatively impact thoracic operative experience for residents in co-located GS programs. Adequate training of both I-6 and GS residents at the same institution is feasible.

Examining the impact of COVID-19 restrictions on the operative volumes of US general surgery residents.

BACKGROUND: In March 2020, the COVID-19 virus global pandemic forced healthcare systems to institute regulations including the cancellation of elective surgical cases, which likely decreased resident operative experience. The objective of this study was to determine whether the COVID-19 pandemic affected operative experiences of US general surgery residents. METHODS: The operative experience of general surgery residents was examined nationally and locally. Aggregate Accreditation Council for Graduate Medical Education (ACGME) case logs for 2018 to 2019 (pre-COVID) and 2019 to 2020 (COVID) graduates were compared using national mean cumulative operative volume for total major and surgeon chief cases. Locally, ACGME case logs were used to analyze the operative experience among residents at a single, academic center. Average operative volumes per month per resident during peak COVID-19 quarantine months were compared with those the previous year. RESULTS: Compared with 2019 graduates, 2020 graduates completed 1.5% fewer total major cases (1055 ± 155 vs 1071 ± 150, P = .011). This was most evident during chief year, with 8.4% fewer surgeon chief cases logged in 2020 compared with 2019 (264 ± 67 vs 289 ± 69, P < .001). Institutional data revealed that during the peak of the pandemic, residents across all levels completed 42.5% fewer total major operations (12 ± 11 vs 20 ± 14, P < .001). This effect was more pronounced among junior residents compared with senior and chief residents. CONCLUSION: The COVID-19 pandemic was associated with decreased resident case volume. The ramifications of the COVID-19 pandemic for operative competency and autonomy should be carefully examined.

The Challenges of Program Accreditation Decisions in 2021 for the ACMGE Review Committee for Surgery.

Through only a few months, the COVID-19 pandemic has greatly impacted the daily activities and education of surgical residents and fellows and the programs in which they are enrolled. The pandemic has also forced many changes for the Accreditation Council for Graduate Medical Education and its Review Committee for Surgery. This article details some of those changes and their effect on the process of conferring 2021 accreditation decisions by the Review Committee.

Trends in Ophthalmology Resident Operative Experience and the Early Impact of the COVID-19 Pandemic.

Purpose This study aimed to evaluate trends in ophthalmology resident operative experience and the early impact of the novel coronavirus disease 2019 (COVID-19) pandemic. Design Present study is a retrospective analysis of the Accreditation Council for Graduate Medical Education (ACGME) Case Log System. Participants Anonymized graduating resident case logs from 2011 to 2020 academic years (AYs) were examined for this study. Methods Regression analysis for each procedure category was performed to identify trends between 2011 and 2019 AYs. Unpaired two-tailed t -test compared 2018 to 2019 and 2019 to 2020 AY's for each category surgeon (S) and as surgeon and assistant (S + A). Main Outcome Measures Mean and median cases as (S) and (S + A) during 2011 to 2019 AYs. Comparison between 2018 to 2019 and 2019 to 2020 AY's for each category as (S) and (S + A) to evaluate the impact of the COVID-19 pandemic. Results Total ophthalmology procedures as (S) rose from a mean of 479.6 to 601.3 ( p < 0.001; R 2 = 0.96; Δ/year = 16.9) and a median of 444 to 537 ( p < 0.001; R 2 = 0.97; Δ/year = 13.1). Total procedures as (S + A) rose from a mean of 698.1 to 768 ( p < 0.01; R 2 = 0.83; Δ/year = 9.07) and a median of 677 to 734 ( p < 0.05; R 2 = 0.61; Δ/year = 6.64). Cataract procedures as (S) rose from a mean of 152.8 to 208 ( p < 0.001; R 2 = 0.99; Δ/year = 7.98) and a median of 146 to 197 ( p < 0.001; R 2 = 0.97; Δ/year = 7.87). Cataract procedures as both (S + A) rose from a mean 231.4 to 268.7 ( p < 0.001; R 2 = 0.95; Δ/year = 5.5) and a median of 213 to 254 ( p < 0.001; R 2 = 0.93; Δ/year = 5.33). Between 2018 to 2019 and 2019 to 2020 AYs, the first pandemic year was associated with significant reductions in total procedures (601.3-533.7 [ p < 0.0001]) as (S) and 768.0 to 694.4 ( p < 0.0001) as (S + A), cataract surgery (208-162.2 [ p < 0.0001]) as (S) and 268.7 to 219.1 ( p < 0.0001) as (S + A), and glaucoma surgery (16.3-14.2 [ p = 0.0068]) as (S) and 25.6 to 22.6 ( p = 0.0063) as (S + A). Conclusion During 2011 to 2019 AYs, cataract, intravitreal injections, glaucoma, and total procedures increased significantly. During the early period of the COVID-19 pandemic (2019-2020 AY), national halting of elective procedures had a precipitous effect on resident cataract surgery experience to volumes similar to 2013 to 2014 AY where the mean was twice the current required minimum number. With few exceptions, other procedure volumes remained stable.

New endocrine fellowship programs do not decrease the endocrine surgery experience of residents in co-located general surgery programs.

BACKGROUND: New pediatric and vascular surgical fellowship programs decrease resident operative experience in those subspecialties in co-located general surgery programs.After 2 decades of increases, the mean number of endocrine surgery cases performed by general surgery residents nationally has decreased since 2010 to 2011. We hypothesized that new endocrine surgery fellowship programs lead to a decrease in the number of endocrine surgery cases performed by co-located general surgery residents and may be a contributing factor in the recent national decline in endocrine surgery cases performed by general surgery residents. METHODS: Endocrine surgery fellowship programs associated with a single, Accreditation Council of Graduate Medical Education-accredited general surgery program that have completed training of 1 fellow by the 2014-2015 academic year were identified. Endocrine surgery cases performed by general surgery residents who completed co-located general surgery programs from 2002 to 2003 through 2017 to 2018 were recorded. Descriptive statistics are shown as mean ± standard deviation. Statistical significance was calculated using the Mann-Whitney U Test. RESULTS: In the 13 general surgery programs with 5 years of case log data after the matriculation of the first fellow, the mean number of total endocrine surgery cases/resident increased from 47 ± 23 in year 0 to 57 ± 25 in year 5 (z-score = 2.53; P < .05). CONCLUSION: New endocrine surgery fellowship programs do not decrease the endocrine surgery cases performed by general surgery residents and have not contributed to the national decline in endocrine surgery cases by general surgery residents.

Analysis of Sex Diversity Trends Among Ophthalmology Match Applicants, Residents, and Clinical Faculty.

IMPORTANCE: The proportion of women in the field of ophthalmology in the US trails the proportion of women in the general population. Sex diversity trends have been studied in other specialties, but there is a dearth of such literature in ophthalmology. OBJECTIVE: To investigate trends in the proportion of female ophthalmology match applicants, residents, and clinical faculty. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study examined data from the San Francisco Match, the Association of University Professors of Ophthalmology, Accreditation Council for Graduate Medical Education, Association of American Medical Colleges, and American Academy of Ophthalmology (AAO) from January 1, 2011, to December 31, 2019. Data from ophthalmology match applicants, residents, clinical faculty at US medical schools, and AAO members were collected. MAIN OUTCOMES AND MEASURES: The proportion of female applicants, residents, and medical school clinical faculty in ophthalmology. RESULTS: Data were obtained from a total of 2807 ophthalmology applicants (35.3% female), 1 004 563 residents (43.8% female), 463 079 clinical faculty members (42.5% female), and 78 968 AAO members (26.1% female). Male ophthalmology residency applicants outnumbered female applicants by a ratio of 1.6:1 from 2016 to 2019. The percentage of female matched applicants in 2016 (41% [168/406]) and 2019 (42% [184/436]) differed by 1% (percent change, 0.99; 95% CI, -1.12 to 3.1; P = .36). There was a 2.3% increase (percent change, 0.34; 95% CI, 0.24-0.43; P < .001) in the percentage of female residents across all surgical specialties from 2011 (39.7% [8710/21 985]) to 2019 (42% [10 951/26 082]) but a 2.5% decrease (percent change, -0.45; 95% CI, -0.84 to -0.06; P = .02) in the percentage of female residents in ophthalmology from 2011 (41.5% [589/1419]) to 2019 (39% [575/1473]). The percentage of female ophthalmology clinical faculty differed by 2% (percent change, 1.02; 95% CI, -0.21 to 2.24; P = .10) from 2017 (38% [1179/3102]) to 2019 (40% [1225/3060]). From 2016 to 2019, male practicing ophthalmologists in the AAO outnumbered female practicing ophthalmologists by a ratio of 3:1. CONCLUSIONS AND RELEVANCE: This study found that the percentage of women in the field of ophthalmology remains lower than percentages in other specialties, and the percentage of female ophthalmology residents has decreased in recent years. More efforts are needed to improve female representation in ophthalmology.

US Medical Licensing Exam Performance and American Board of Surgery Qualifying and Certifying Examinations.

BACKGROUND: Program directors use US Medical Licensing Exam (USMLE) scores as criteria for ranking applicants. First-time pass rates of the American Board of Surgery (ABS) Qualifying (QE) and Certifying (CE) Examinations have become important measures of residency program quality. USMLE Step 1 will become pass/fail in 2022. STUDY DESIGN: American Board of Surgery QE and CE success rates were assessed considering multiple characteristics of highly ranked (top 20) applicants to 22 general surgery programs in 2011. Chi-square, t-test, Wilcoxon Rank sum, linear and logistic regression were used, as appropriate. RESULTS: The QE and CE first attempt pass rates were 96% (235/244) and 86% (190/221), respectively. QE/CE success was not significantly associated with sex, race, research experience, or publications. Alpha Omega Alpha (AΩA) status was associated with success on the index CE (98% vs 83%; p = 0.008). Step 1 and Step 2 Clinical Knowledge (CK) scores of surgeons who passed QE on their first attempt were higher than scores of those who failed (Step 1: 233 vs 218; p = 0.016); (Step 2CK: 244 vs 228, p = 0.009). For every 10-point increase in Step 1 and 2CK scores, the odds of passing CE on the first attempt increased 1.5 times (95% CI 1.12, 2.0; p = 0.006) and 1.5 times (95% CI 1.11, 2.02, p = 0.008), respectively. For every 10-point increase in Steps 1 and 2CK scores, the odds of passing the QE on the first attempt increased 1.85 times (95% CI 1.11, 3.09; p = 0.018) and 1.86 times (95% CI 1.14, 3.06, p = 0.013), respectively. CONCLUSIONS: USMLE Step 1 and Step 2 CK examination scores correlate with American Board of Surgery QE and CE performance and success. The USMLE decision to transition Step 1 to a pass/fail examination will require program directors to identify other factors that predict ABS performance for ranking applicants.

Where Has All the Complexity Gone? An Analysis of the Modern Surgical Resident Operative Experience.

OBJECTIVES: The operative experience of today's general surgery (GS) residents are changing. The Surgical Council on Resident Education (SCORE) was founded to provide a standardized, competency-based curriculum. We set out to evaluate resident operative experience in core and advanced operations. DESIGN: Accreditation Council for Graduate Medical Education (ACGME) national operative log reports from 2010 to 2018 were reviewed. Operative volume data for 344 operations were extracted and analyzed. Operations were designated as core, advanced, or undefined as listed by SCORE, and stratified as GS or subspecialty. SETTING: National analysis utilizing ACGME operative log reports. PARTICIPANTS: All graduating general surgery residents between 2010 and 2018. RESULTS: A total of 10,118 residents completed GS training with an average of 1121.5 ± 29.3 total cases. Core operations comprised 80.5% of total volume while advanced comprised only 8.0%. The total core experience increased (+7.0 cases/year), while total advanced experience decreased (-1.4 cases/year) (p < 0.01 each). Compositional analysis among core operations revealed an increase in 9/13 GS domains and a decrease in 8/10 subspecialty domains (all p < 0.05). CONCLUSIONS: There has been an increase in core operative experience with a concurrent decrease in advanced operative experience of graduating GS residents. These findings highlight the continued narrowing of the operative experience for trainees, with increasing focus on GS and less on subspecialty domains. Ongoing efforts to look beyond operative volume to ensure competency of graduates will prove beneficial.

More of less: General Surgery Resident Experience in Biliary Surgery.

BACKGROUND: The scope of operations performed by surgery residents has progressively narrowed. This analysis was undertaken to determine the degree to which that narrowing has occurred in one particular operative domain-biliary surgery. STUDY DESIGN: The total numbers of major cases and biliary cases by resident role were abstracted from annual ACGME national case log reports from 1989 to 1990 through 2017 to 2018, as were the number of total operations performed by residents in each biliary case category. Trends were analyzed. RESULTS: The total numbers of major cases and biliary cases performed throughout residency have increased considerably. For chief residents, the total number of major cases has declined, but the total number of biliary cases has increased slightly. The increase in the total number of biliary cases performed is due entirely to laparoscopic cholecystectomy. All other types of biliary operations have decreased substantially in number and are now performed rarely. For 2018 graduates, laparoscopic cholecystectomy accounted for 11.2% of all major operations throughout residency and 11.7% of chief resident operations. CONCLUSIONS: Resident operative experience in biliary surgery has increased considerably both in absolute numbers and as a proportion of overall operative experience, but is increasingly limited to laparoscopic cholecystectomy.

Hysterectomy Route and Numbers Reported by Graduating Residents in Obstetrics and Gynecology Training Programs.

OBJECTIVE: To characterize trends in self-reported numbers and routes of hysterectomy for obstetrics and gynecology residents using the Accreditation Council for Graduate Medical Education (ACGME) case log database. METHODS: Hysterectomy case log data for obstetrics and gynecology residents completing training between 2002-2003 and 2017-2018 were abstracted from the ACGME database. Total numbers of hysterectomies and modes of approach (abdominal, laparoscopic, and vaginal) were compared using bivariate statistics, and trends over time were analyzed using simple linear regression. RESULTS: Hysterectomy data were collected from 18,982 obstetrics and gynecology residents in a median of 243 (interquartile range 241-246) ACGME-accredited programs. The number of graduating residents increased significantly over time (12.1/year, P<.001), whereas the number of residency programs decreased significantly (0.52 fewer programs per year, P<.001) over the 16-year period. For cases logged as "surgeon," the median number of abdominal hysterectomies decreased by 56.5% from 85 (interquartile range 69-102) to 37 (interquartile range 34-43) (P<.001). The median number of vaginal hysterectomies decreased by 35.5% from 31 (interquartile range 24-39) to 20 (interquartile range 17-25) (P=.002). The median total number of hysterectomies per resident decreased by 6.3% from 112 (interquartile range 97-132) to 105 (interquartile range 92-121) (P=.036). In contrast, the median number of laparoscopic hysterectomies increased by 115% from 20 (interquartile range 13-28) in 2008-2009 to 43 (interquartile range 32-56) in 2017-2018, despite the decrease in overall number of hysterectomies (P<.001). These trends were statistically significant. CONCLUSIONS: The total number of hysterectomies performed by obstetrics and gynecology residents in the United States is decreasing, and the routes are changing with decreases in abdominal and vaginal approaches, and an increase in use of laparoscopic hysterectomy.

The ups and downs of general surgery resident experience in endocrine surgery: Analysis of 30 years of ACGME graduate case logs.

BACKGROUND: The aim of this study was to determine trends in the experience of general surgery residents with endocrine surgery cases. METHODS: American Association of Endocrine Surgeons national general surgery case logs from 1989 through 2019 were reviewed. The numbers of individuals completing residency and the mean and median number of endocrine surgery cases by type and by level of operating resident surgeon were abstracted from annual data and analyzed. Descriptive statistics and linear regression analyses were performed modeling endocrine surgery cases over time and stratified by procedure type and resident level. RESULTS: The number of individuals completing general surgery residency each year increased from 981 to 1,219 (P < .001). The average total number of endocrine surgery cases performed increased from 17 to 33.2 (P < .001) but has declined since its peak at 36.9 in 2010 to 2011 (P = .014). Thyroid operations increased from 11.4 to 19.8 (P < .001) but peaked at 23.5 in 2010 to 2011 and have since declined (P < .001). Parathyroid operations more than doubled from 4.2 to 9.7 (P < .001). Adrenal operations increased from 1 to 2.2 (P < .001) and pancreatic endocrine operations increased from 0.2 to 1.5 (P < .001). Surgeon Chief endocrine surgery cases peaked at 14.4 in 2003 to 2004 but have since declined by 22.2% (P < .001). Surgeon Junior endocrine surgery cases increased overall (P < .001) but peaked at 22.8 in 2011 to 2012. There was increasing heterogeneity over time in trainee experience (P < .001). CONCLUSION: After having increased for 2 decades, the number of endocrine surgery cases performed by general surgery residents is currently in decline. Possible contributing factors include growth in the number of general surgery residents, variable and narrowed case mix, and encroachment by other learners.