Declining Operative Experience for Junior-Level Residents: Is This an Unintended Consequence of Minimally Invasive Surgery?

Abstract

Introduction Our group has previously demonstrated an upward shift from junior to senior resident participation in common general surgery operations, traditionally performed by junior level residents. The objective of this study was to evaluate if this trend would correct over time. We hypothesized that junior resident case volume would improve. Methods A sample of essential laparoscopic and open general surgery procedures (appendectomy, inguinal herniorrhaphy, cholecystectomy, and partial colectomy) was chosen for analysis. The ACS NSQIP Participant Use Files were queried for these procedures between 2005–2012. Cases were stratified by participating resident post-graduate year (PGY) with ‘junior resident’ defined as PGY1–3. Logistic regression was performed to determine change in junior resident participation for each type of procedure over time. Results 185,335 cases were included in the study. For three of the operations we considered, the prevalence of laparoscopic surgery increased from 2005–2012 (all p<0.001). Cholecystectomy was an exception, which showed an unchanged proportion of cases performed laparoscopically across the study period (p=0.119). Junior resident participation decreased by 4.5%/year (p<0.001) for laparoscopic procedures and by 6.2%/year (p<0.001) for open procedures. The proportion of laparoscopic surgeries performed by junior level residents decreased for appendectomy by 2.6%/year (p<0.001) and cholecystectomy by 6.1%/year (p<0.001), whereas it was unchanged for inguinal herniorrhaphy (p=0.75) and increased for partial colectomy by 3.9%/year (p=0.003). A decline in junior resident participation was seen for all open surgeries, with appendectomy decreasing by 9.4%/year (p<0.001), cholecystectomy by 4.1%/year (p<0.002), inguinal herniorrhaphy by 10%/year (p<0.001) and partial colectomy by 2.9%/year (p<0.004). Conclusions Along with the proliferation of laparoscopy for common general surgical procedures there has been a concomitant reduction in the participation of junior level residents. As previously thought, familiarity with laparoscopy has not translated to redistribution of basic operations from senior to junior residents. This trend has significant implications for general surgery resident education.

Comparative study of the operative experience of surgical residents before and after 80-hour work week restrictions

“…This is also confirmed by the fact that laparoscopic appendectomy is the surgery that showed the highest increase among surgeries by R3. This is similar to the findings by Mullen et al [ 11 ], reporting that, along with the proliferation of laparoscopy for common general surgical procedures, there has been a concomitant reduction in the participation of junior-level residents. With respect to surgical experience at both time points, it was confirmed that the R3 were most active.…”

Current status of pain medicine training in anesthesiology and pain medicine residency programs in university hospitals of Korea: a survey of residents’ opinions

“…In Korea, this policy has been adopted for a balance between wellness and proper training experience among residents since the end of 2015. However, there are some concerns, such as the negative effects due to significant reduction in case volume and inadequate training experience 1 9 10. Swide and colleagues reported that work-hour restriction improves resident’s wellness, but improvement in patient safety or residents’ quality of education remained unclear based on a survey conducted by the US anesthesiology residency program 11.…”

“…Considering the variation in educational environments and each specialty’s characteristics, changes to the educational programs will be needed in the future 14. To provide better opportunities for learning interventional techniques, alternative training methods, including simulation program, bench models, virtual tools, phantom models and live animal models will be needed to improve basic skills 1 15–20. In addition, we suggest that the current PM training goal be changed to reflect the residents’ opinions of low interventional opportunity and more ultrasound block learning.…”

“…In general surgery, there is a concern that residents feel unprepared to practice independently after the residency training; and 70% of the graduating residents choose to pursue further fellowship training 1 2. Familiarity with developing surgical procedures is not being translated from senior to junior residents as a result of several factors including work-hour limitation and systemic diversity in training environments 1. Therefore, there are concerns that this trend has significant implications on resident education in general practice 1.…”

“…Familiarity with developing surgical procedures is not being translated from senior to junior residents as a result of several factors including work-hour limitation and systemic diversity in training environments 1. Therefore, there are concerns that this trend has significant implications on resident education in general practice 1. In Korea, there are no published data regarding the current state of residency program in relation to PM training.…”