Brief communication of the Residency Review Committee-Surgery (RRC-S) on residents' surgical volume in general surgery

Kirby I Bland, Doris A Stoll, J David Richardson, L D Britt
American Journal of Surgery 2005, 190 (3): 345-50

BACKGROUND: The Residency Review Committee-Surgery (RRC--S), 1 of 10 surgical specialties of the Accreditation Council for Graduate Medical Education (ACGME) has monitored the surgical volume of all general surgical residents closely. As a consequence of the reduction of duty hours with the limitation of an 80-hour work-week (averaged over 4 weeks), we were interested in the impact of these restrictions on surgical (volume) experience since its first year of implementation (2003--2004). Therefore, we evaluated the surgical volume of general surgical services since the implementation of the ACGME duty-hour restrictions and compared this volume with that of previous years without these duty limits.

METHODS: The Biostatistical Management Section of the ACGME implemented prospective analysis of categorized data for total surgical procedures and Chief Resident cases. The study interval included all resident surgical procedures completed from 1997 to 2004. We were interested particularly in evaluating trends and outcomes after the first year of successful full compliance of the 80-hour work week. Specific evaluations included the impact on surgical programs for total major procedures and Chief Resident cases requisite for application to the American Board of Surgery.

RESULTS: The average number of total major procedures for both resident and program averages were noted to increase steadily through the academic years of evaluation (1997--2001). A sharp decrease was evident in the total major procedures for the academic year 2001--2002 that relates to a correction of the biostatistical database implemented by the ACGME to correct a system conversion that began in the academic year 2001--2002. Despite significant changes to the system data mappings, beginning in the academic year 2001, this reduction is explained by the total counted surgeries as major that were eliminated in a revised counting methodology. It was evident on evaluation of the average (of averages) for major surgical procedures per resident (per program) in academic years 1997 to 2004 that the number of procedures was not statistically different in the academic years evaluated when compared with the year for implementation of duty-hour standards (2003--2004). Data analysis further indicates that the average procedures (per resident) performed as Chief Resident in general surgery remained stable from 1997 to 2004; the use of tiered t tests comparing Chief Resident averages (per program) for the academic years 2002--2003 versus 2003--2004 indicated that data remained consistent and confirmed no statistical variance in volumes during this interval (P=0.43). Because some general surgery programs have exceptions for duty-hour requirements (n=15) to allow an 88-hour week averaged over 4 weeks, these differences were of interest to evaluate programs with and without these duty-hour exceptions. Preliminary data with these limited parameters of evaluation suggest no detrimental outcomes related to the duty-hour restrictions for total major procedures per resident or for surgical procedures as Chief Residents for programs with and without these approved exceptions.

CONCLUSIONS: RRCs that evaluate general surgery and surgical specialties have responded aggressively and professionally to implement the duty-hour standards per the ACGME. This brief report should be considered an interim communication to evaluate the surgical experience impact for programs currently under the restriction of duty-hour limits. The data provided in the first year of evaluation since the implementation of the 80-hour work-week restriction policy suggest that there has been no significant change in the overall surgical experience for major procedures (per resident), nor has there been a negative impact on Chief Resident surgical experience. A continuum of the prospective evaluation process is required by the RRC-S and other surgical specialties to ensure that requisite surgical volume is maintained throughout the entire 5 years of clinical surgery.

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