General surgery workloads and practice patterns in the United States, 2007 to 2009: a 10-year update from the American Board of Surgery.

OBJECTIVE: To assess changes in general surgery workloads and practice patterns in the past decade. BACKGROUND: Nearly 80% of graduating general surgery residents pursue additional training in a surgical subspecialty. This has resulted in a shortage of general surgeons, especially in rural areas. The purpose of this study is to characterize the workloads and practice patterns of general surgeons versus certified surgical subspecialists and to compare these data with those from a previous decade. METHODS: The surgical operative logs of 4968 individuals recertifying in surgery 2007 to 2009 were reviewed. Data from 3362 (68%) certified only in Surgery (GS) were compared with 1606 (32%) with additional American Board of Medical Specialties certificates (GS+). Data from GS surgeons were also compared with data from GS surgeons recertifying 1995 to 1997. Independent variables were compared using factorial ANOVA. RESULTS: GS surgeons performed a mean of 533 ± 365 procedures annually. Women GS performed far more breast operations and fewer abdomen, alimentary tract and laparoscopic procedures compared to men GS (P < 0.001). GS surgeons recertifying at 10 years performed more abdominal, alimentary tract and laparoscopic procedures compared to those recertifying at 20 or 30 years (P < 0.001). Rural GS surgeons performed far more endoscopic procedures and fewer abdominal, alimentary tract, and laparoscopic procedures than urban counterparts (P < 0.001). The United States medical school graduates had similar workloads and distribution of operations to international medical graduates. Compared to 1995 to 1997, GS surgeons from 2007 to 2009 performed more procedures, especially endoscopic and laparoscopic. GS+ surgeons performed 15% to 33% of all general surgery procedures. CONCLUSIONS: GS practice patterns are heterogeneous; gender, age, and practice setting significantly affect operative caseloads. A substantial portion of general surgery procedures currently are performed by GS+ surgeons, whereas GS surgeons continue to perform considerable numbers of specialty operations. Reduced general surgery operative experience in GS+ residencies may negatively impact access to general surgical care. Similarly, narrowing GS residency operative experience may impair specialty operation access.

Comparison of surgical operative experience of trainees and practicing vascular surgeons: a report from the Vascular Surgery Board of the American Board of Surgery.

INTRODUCTION: The Vascular Surgery Board (VSB) of the American Board of Surgery sought to answer the following questions: what is the scope of contemporary vascular surgery practice? Do current vascular surgery residents obtain training that is appropriate for their future career expectations and for successful Board certification? How effectively do practicing vascular surgeons incorporate emerging technologies and procedures into practice? METHODS: We analyzed the operative logs submitted to the VSB by recent vascular surgery residents applying for the Vascular Surgery Qualifying Examination (QE; 2006-2009) or by practicing vascular surgeons applying for the Vascular Surgery Recertification Examination (RE; 1995-2009). The relationship between reported operative experience and performance of the QE and RE was examined. RESULTS: There has been a threefold increase in the mean number of primary cases reported by both RE and QE applicants over the past 15 years and the increase in case volume has been driven largely by an increase in the number of endovascular procedures. Endovascular procedures have been broadly incorporated into the practice of most vascular surgeons applying for recertification. The number of major open surgical cases reported by recent QE applicants has remained unchanged over the period of observation. For QE applicants, the number of endovascular aneurysm repairs (EVARs) has reached a plateau at approximately 50 cases, whereas the mean number of open infrarenal aneurysm repairs has decreased for both QE and RE applicants, reflecting national trends favoring EVAR. There was a significant association between case volume and performance on the QE but not on the RE. CONCLUSION: Over the past 15 years, there has been a significant increase in the total number of operative cases reported to the VSB by both QE and RE applicants. Contrary to popular belief, the volume of major open vascular surgery reported by recent vascular surgery residents has remained relatively stable since 1994. Over the same time period, endovascular procedures have been rapidly incorporated into clinical practice by the majority of vascular surgeons applying for recertification by the VSB. Current vascular surgery residents receive a rich operative experience in both open and endovascular procedures that is reflective of contemporary practice.

Operative experience of residents in US general surgery programs: a gap between expectation and experience.

OBJECTIVE: The purpose of the study was to identify a group of operations which general surgery residency program directors believed residents should be competent to perform by the end of 5 years of training and then ascertain actual resident experience with these procedures during their training. SUMMARY BACKGROUND DATA: There is concern about the adequacy of training of general surgeons in the United States. The American Board of Surgery and the Association of Program Directors in Surgery undertook a study to determine what operative procedures residency program directors consider to be essential to the practice of general surgery and then we measured the actual operative experience of graduating residents in those procedures, as reported to the Residency Review Committee for Surgery (RRC). METHODS: An electronic survey was sent to residency program directors at the 254 general surgery programs in the US accredited by the RRC as of spring 2006. The program directors were presented with a list of 300 types of operations. Program directors graded the 300 procedures "A," "B," or "C" using the following criteria: A--graduating general surgery residents should be competent to perform the procedure independently; B--graduating residents should be familiar with the procedure, but not necessarily competent to perform it; and C--graduating residents neither need to be familiar with nor competent to perform the procedure. After ballots were tallied, the actual resident operative experience reported to the RRC by all residents finishing general surgery training in June 2005 was reviewed. RESULTS: One hundred twenty-one of the 300 operations were considered A level procedures by a majority of program directors (PDs). Graduating 2005 US residents (n = 1022) performed only 18 of the 121 A procedures, an average of more than 10 times during residency; 83 of 121 procedures were performed on an average less than 5 times and 31 procedures less than once. For 63 of the 121 procedures, the mode (most commonly reported) experience was 0. In addition, there was significant variation between residents in operative experience for specific procedures. In virtually all cases, the mean reported experience exceeded the mode, suggesting that the mean is a poor measure of typical experience. CONCLUSIONS: These data pose important problems for surgical educators. Methods will have to be developed to allow surgeons to reach a basic level of competence in procedures which they are likely to experience only rarely during residency. Even for more commonly performed procedures, the numbers of repetitions are not very robust, stressing the need to determine objectively whether residents are actually achieving basic competency in these operations. Finally, the large variations in experience between individuals in our residency system need to be explored, understood, and remedied.

Certification and maintenance of certification in surgery.

The processes that lead to certification by the American Board of Surgery (ABS) emphasize surgeons' training and qualifications. Moreover, the need for periodic recertification appears to provide strong motivation for surgeons to remain current. Such certification is regarded as having great value among patients, but concerns about quality and safety have increased pressure to assess what surgeons actually do in practice. As a result, the American Board of Medical Specialties (ABMS) member boards have recently initiated Maintenance of Certification (MOC) programs that add a requirement for assessment of practice performance to the elements of traditional certification. This article describes the current ABS certification process and the ABS MOC program in greater detail.

Graduate medical education in surgery in the United States.

Each year, approximately 1000 graduating medical students enter 5-year residency programs in general surgery. Their salaries are funded by the federal government. Following 5 years of general surgery training, approximately 70% of graduates enroll in a specialty fellowship. Surgery training currently faces a number of challenges, including the diminishing attractiveness of surgery as a career, attrition from residency programs, mandated work hour limits, extensive service requirements in the hospital environment, increasing specialization, and changing patient expectations about the role of residents in their care, among others. In the face of these challenges, the profession is beginning to respond to the need for positive change in the process of training surgeons.

Maintenance of certification.

Maintenance of Certification (MOC) is the most recent stage in the evolution of specialty board certification. Driven by increasing concerns over the quality and safety of medical care, MOC represents a change in the frequency and the nature of the requirements of existing recertification. Under MOC, the every 10-year snapshot of professionalism, participation in continuing medical education, and medical expertise that are part of current recertification will become a more continuous process. MOC adds the assessment of practice performance to these measures and represents a philosophical change as well as a requirement change. The focus of these assessments is for improvement rather than judgment. The extent to which MOC succeeds will reflect surgeons' ability to improve the quality of care through voluntary efforts.

Surgical Training and the Early Specialization Program: Analysis of a National Program.

BACKGROUND: The Early Specialization Program (ESP) in surgery was designed by the American Board of Surgery, the American Board of Thoracic Surgery, and the Residency Review Committees for Surgery and Thoracic Surgery to allow surgical trainees dual certification in general surgery (GS) and either vascular surgery (VS) or cardiothoracic surgery (CTS) after 6 to 7 years of training. After more than 10 years' experience, this analysis was undertaken to evaluate efficacy. STUDY DESIGN: American Board of Surgery and American Board of Thoracic Surgery records of VS and CTS ESP trainees were queried to evaluate qualifying exam and certifying exam performance. Case logs were examined and compared with contemporaneous non-ESP trainees. Opinions of programs directors of GS, VS, and CTS and ESP participants were solicited via survey. RESULTS: Twenty-six CTS ESP residents have completed training at 10 programs and 16 VS ESP at 6 programs. First-time pass rates on American Board of Surgery qualifying and certifying exams were superior to time-matched peers; greater success in specialty specific examinations was also found. Trainees met required case minimums for GS despite shortened time in GS. By survey, 85% of programs directors endorsed satisfaction with ESP, and 90% endorsed graduate readiness for independent practice. Early Specialization Program participants report increased mentorship and independence, greater competence for practice, and overall satisfaction with ESP. CONCLUSIONS: Individuals in ESP programs in VS and CTS were successful in passing GS and specialty exams and achieving required operative cases, despite an accelerated training track. Programs directors and participants report satisfaction with the training and confidence that ESP graduates are prepared for independent practice. This documented success supports ESP training in any surgical subspecialty, including comprehensive GS.

Voluntary changes in surgery career paths: a survey of the program directors in surgery.

BACKGROUND: This article attempts to quantify the current scope of attrition, identify the reasons why categorical residents are leaving general surgery residency programs voluntarily, and correlate the program directors' and residents' perspectives. STUDY DESIGN: A questionnaire asked the Program Directors of general surgery residency programs how many categorical residents left voluntarily in the 2000-2001 academic year, their postgraduate (PGY) levels, why they left, and where they went. Another questionnaire asked the residents why they entered surgery and why they left. The surveys' responses were compared. RESULTS: A total of 206 programs (81%) responded. One hundred ten programs (53%) reported voluntarily attrition of 167 categorical residents (mean: 0.8 residents per program for all responders and 1.5 residents per program for programs that reported attrition). Seventy-three programs (66%) lost one resident; 23 programs (21%), 2 residents; 9 programs (8%), 3 residents; 4 programs (4%), 4 residents; and 1 program (<1%), 5 residents. Eighty-five PGY-1 residents (51%), 42 PGY-2 residents (25%), 27 PGY-3 residents (16%), and 13 PGY-4 residents (8%) left. The most common reasons for attrition cited by the program directors were personal and work hours/lifestyle in 40% and 35%, respectively. One hundred five residents (63%) entered other fields of medicine; 40 residents transferred to other general surgery programs. Net voluntary attrition, defined as the number of residents who left general surgery voluntarily (127) divided by the resident population at risk, was 3%, indicating that 97% of the residents at risk in the responding programs remained in general surgery. CONCLUSIONS: Most surgery programs that responded were affected by attrition in 2000-2001, with approximately one-third losing more than one resident. Attrition tends to occur early in training. Most residents enter other specialties, primarily for quality-of-life reasons. But many stay in general surgery.

Continuing medical education activity and American Board of Surgery examination performance.

BACKGROUND: Surgical knowledge is the basis of successful clinical problem solving, so is thought to be an important component of overall clinical ability. Continuing medical education (CME) reinforces basic knowledge and provides exposure to new knowledge within a field. Specialty board examination performance measures this knowledge but few studies have investigated a link between such performance and CME activity. This study assessed that link on the American Board of Surgery Recertification Examination. STUDY DESIGN: The study sample comprised 278 randomly chosen applicants for the 2000 examination. Study variables included practice type, career activity, age, gender, other Board certifications, examination attempts, community size, geographic region, nationality, and ethnicity. RESULTS: The study sample was remarkably similar to the total candidate cohort with regard to study variables. Of the 245 sample Diplomates who took the Recertification Examination, 10.2% failed. The Pass group reported 53% more total CME hours and 38% more Category I CME hours than the Fail group. The vast majority of Category I activities were surgical, clinical. Analyzed by quartiles of total CME hours, the failure rate was only 3.4% for the highest quartile but 25.8% for the lowest quartile. For Category I hours, respective failure rates were 4.8% and 19.4%. When further stratified by practice type, the failure rate of those in solo practice was 6% for those in the highest quartile of total CME hours and 37% for those in the lowest quartile. For Category I hours, the respective failure rates were 0% and 31%. CONCLUSIONS: There is a strong relationship between CME activity and performance on the American Board of Surgery Recertification Examination. Low CME activity and practice type appear to be independent risk factors for examination failure. The relationship of these findings to patient care outcomes has important implications.

How do general surgery replacement residents match up with those recruited through the National Resident Matching Program?

BACKGROUND: Although the scope and patterns of attrition of general surgery residents have been reported, no study has examined the residents who replaced them. The purpose of this study was to assess the quality of replacement residents (RRs). METHODS: A questionnaire asked program directors (PDs) about the prevalence, characteristics, and disposition of RRs in general surgery residency programs from 2001 to 2002. RESULTS: PDs from 169 programs (67%) responded, and 109 (64%) of these programs had RRs. Of 244 RRs (7%), 18 (7%) were postgraduate year (PGY)-1 residents; 64 (26%) were PGY-2 residents; 77 (32%) were PGY-3 residents; 52 (21%) were PGY-4 residents; and 33 (14%) were PGY-5 residents. RRs averaged 1.9 years in their programs. One hundred seventy-five (72%) came from outside the current institution, and 142 had (58%) graduated from U.S. medical schools. PDs judged RRs to be superior (20%), comparable (55%), or inferior (25%) to their peers. Neither internal recruitment nor United States medical school graduation predicted performance. Disposition included promotion and graduation (88%), leaving the program voluntarily (5%), repeating the year (4%), and dismissal (3%). Successful RR performance occurred in 71% of RRs. CONCLUSIONS: Typically, RRs were U.S. medical school graduates, were recruited from outside the institution, and have performed satisfactorily.

Association between patient-controlled analgesia pump use and postoperative surgical site infection in intestinal surgery patients.

BACKGROUND: Patient-controlled analgesia (PCA) pumps are widely used after surgery, but their association with various outcomes is not completely understood. Is PCA pump use related to the incidence of postoperative surgical site infections among patients undergoing open intestinal surgery? MATERIALS AND METHODS: We undertook a comprehensive retrospective chart review of 515 randomly selected patients over age 18 who had major rectal or intestinal surgery (Diagnosis Related Groups [DRGs] 146-149) between January 1994 and March 1997 from eight community or teaching hospitals along the U.S. west coast. Of these patients, 214 used PCA pumps. Outcome measures were in-hospital postoperative surgical site infections, respiratory complications, ileus/abdominal distention, urinary tract infection/urinary retention, and length of stay. RESULTS: Use of a PCA pump was significantly associated with increased in-hospital postoperative surgical site infections (10.7% for PCA, 4.0% for no PCA). The odds ratio for PCA use was about 4.0 after controlling for many variables, including severity of illness at admission, body mass index, preadmission use of corticosteroids, perforated viscus, number of previous abdominal operations, wound classification category, hypothermia, malnutrition on admission, preoperative antibiotic use within 2 h before incision, time from hospital admission to surgery, skin prep to incision time, anesthesia start to incision time, surgical skin to skin time, wound closure type, time from incision closure to the start of PCA, use of drains, blood product use, central line use, line infection, mobility assistance required, hospital, DRG, and surgeon. CONCLUSION: No confounding variables explained the significant association between PCA pump use and in-hospital surgical site infection. These results stand firmly on data that merit additional study to further elucidate possible immunologic effects of PCA pumps.

Evolving patterns of vascular surgery care in the United States: a report from the American Board of Surgery.

BACKGROUND: The purpose of this study was to analyze the distribution of major vascular procedures among general and vascular surgeons and to compare the evolution of vascular surgical practice of general and vascular surgeons at specific points in their careers. STUDY DESIGN: Case logs of surgeons seeking recertification in surgery from 2007 to 2009 were reviewed. Data from 3,362 physicians certified only in surgery (GS) were compared with 363 additionally certified in vascular surgery (VS). Independent variables were compared using factorial ANOVA. RESULTS: The mean numbers of major vascular procedures (±SD) were 10 ± 51 for GS and 192 ± 209 for VS (p < 0.001). Thirty-three percent of the total vascular procedures reported were performed by GS. Compared with VS, GS performed significantly fewer vascular procedures in all major procedure categories, and GS certifying at 10 years performed fewer vascular procedures (6.7 ± 47) than those recertifying at 20 years (11.5 ± 48) and 30 years (13.6 ± 59) (p < 0.01). In contrast, VS certifying at 10 years performed more vascular procedures (235 ± 237) compared with those recertifying at 20 years (157 ± 173) and 30 years (104 ± 115). The mean number of vascular procedures was not different for sex, geographic location, or practice type, after controlling for other variables in the study. CONCLUSIONS: The majority of GS currently do not perform any major vascular procedures, and younger GS are performing fewer such procedures than their older counterparts. The opposite is true for VS. These opposing trends indicate that vascular procedures are shifting from GS to VS in modern surgical practice, and this may have important implications for patient access to vascular surgery care, considering the limited capacity for VS to assume the excess case load.

[Evolution of vascular surgery and vascular surgery training: lessons learned.]

Over the last decade, surgery as a discipline, and vascular surgery in particular, has been faced with a rapid growth in the scope of knowledge and array of techniques to be mastered by the graduating resident and the constraints of work hour limitations. In response, the U.S. vascular surgery community significantly altered its surgical training curriculum. This article will discuss the factors that prompted these changes, the challenges that continue to face vascular surgery education and the expectations for the future. We will also comment on the relevance of this experience to other surgical specialties.

Motivations to pursue fellowships are gender neutral.

OBJECTIVE: To determine the importance of factors in decision making by general surgery chief residents to pursue fellowships and to relate factor importance to gender and residency characteristics. DESIGN: Prospective, voluntary, national survey conducted April through May, 2008, in which finishing chief residents rated the importance of 12 factors in their decision making to pursue fellowships. SETTING: General surgery chief residents who applied for admission to the American Board of Surgery Qualifying Examination process. PARTICIPANTS: All 1034 first-time applicants. MAIN OUTCOME MEASURES: chi(2) tests and 1-way analyses of variance were used to correlate gender and residency type, size, and location with summed values and scaled mean scores for ratings of the importance of 12 potential factors in fellowship decision making. RESULTS: The fellowship rate was 77% and correlated with residency size and location. Women were dispersed asymmetrically across residencies overall but future female fellows were distributed similarly to male ones. Survey item response rates for future fellows were 96% to 98%. Clinical mastery and specialty activities were valued most highly by more than 90% of men and women. Men placed more value on income potential and spousal influence. Lifestyle factors reached only midrange importance for both genders. Program size had more significant relationships to decision-making factors than did gender. CONCLUSIONS: The ability to master an area of clinical practice and the clinical activities of a specialty are the most important factors for chief residents in fellowship decision making, regardless of gender. Lifestyle factors are of midrange importance. Program size is as influential as is gender.