Jonathan Fryer, MD, Jeff Fronza , MD, Jeff Wayne, MD,

Surgical Residents’ Perception of Competence & Relevance of the

Clinical Curriculum to Future Practice

Jonathan Fryer, MD, Jeff Fronza, MD, Jeff Wayne, MD,

Debra DaRosa, PhD, and Jay Prystowsky, MD, MHPE

Northwestern University Feinberg School of Medicine

Graduation Requirements?*

A = “essential” B = “should be”C = “not necessary”

121 operations = “essential” components of GS resident training by majority of PD’s (n=114/254)

*R.H. Bell, Surgical council on resident education: a new organization devoted to graduate surgical education, J Am Coll Surg 204 (2007), pp. 341–346.

But……

For 52% (63/121) of the “essential” cases, the mode no. of cases/resident = 0!

These included cases such as:

CBDE

Transanal tumor excision

Anal fistulotomy

Research Questions

1. To what extent do our graduates feel competent with selected operations?

2. How relevant are these operations to their current practices?

3. Is there a relationship between the number of cases logged and post residency perceived competence?

Subjects

2005

3

2006

4

2007

4

2008

5

2009

5

2010

5

Total

26

Survey Instrument = 67 Operations

Burn (4)

Pediatric (6)

Anorectal

(4)Trauma

(5)

Breast (4) Vascular (6)

Skin/Soft Tissue (4)

Thoracic (5)

Endocrine (4)

Abdominal /Alimentary

( 23)Endoscopy

(2)

Survey Instrument Each operation= two 4-point scales

SA A D SD

“I was well-prepared to work-up, independently perform this operation, and effectively care for the patient post-operatively” (i.e. COMPETENCE)

“This operation is relevant to my current practice profile” (i.e. RELEVANCE)

Data Collection Annual electronic survey sent out in January to

all general surgery residents graduating the previous year.

Case logs were reviewed for each resident compiling total case volume by operations listed on the survey.

Statistical analysis

• Frequency counts and means were calculated for both survey scales for each operation.

• Linear regression analysis - correlation between perceptions of competence and total major procedural case volumes.

• Unpaired Student-T-tests - compared mean case #s for each procedure performed by residents’ who felt competent (SA+A) vs. those performed by those who did not feel competent (D+SD).

ResultsPostgraduate Track # (n= 22)

Surgical Oncology 5Minimally Invasive Surgery 4Cardiothoracic 3Colorectal 2Plastic Surgery 2Pediatric Surgery 2Breast 1Endocrine 1Non fellowship track 2

Least Relevant Operations

• Procedure for NEC

• Orchiopexy

• CEA

• Creation of dialysis access fistula

• Major amputation

• Endovascular repair of AAA

• Infrainguinal arterial bypass

• Debridement of eschar

Most Relevant Operations

• Exploratory laparotomy with LOA

• Open chole

• Lap chole• Ventral hernia

repair• Partial gastrectomy

• Enterectomy w/ anastomosis

• Colectomy, partial w/ anastomosis

• Colectomy, partial w/ coloproctostomy

• G-tube or J-tube inserts

Highest Competence

• Inguinal hernia >5 yrs• Exploratory lap w/ LOA• Open chole• Lap chole• Enterectomy w/

anastomosis• Colectomy, partial w/

anastomosis

• G-tube/J-tube insertion• Partial gastrectomy• Wedge resection of liver• Needle breast bx• Simple mastectomy• SLNB• Total thyroidectomy• Parathyroidectomy

Least Competence

• Surgical treatment of NEC

• Orchiopexy

• Transhiatal esophagectomy

• Adrenalectomy

• Open AAA repair

• Endovascular AAA repair

100% Respondents Perceived Competence

24%

Operations (16 of 67)

90% Respondents Perceived Competence

52%

Operations (34 of 67)

50% Respondents Perceived Competence

Operations (60 of 67)

90%

Procedural Volume vs. Competence

– For total major procedural volume• No correlation (r = 0.343; p=0.12)

– For individual procedural volume• +ve correlation with four procedures

– Esophagectomy (p=0.014)– Orchiopexy (p=0.03)– EGD (p=0.018)– Adrenalectomy (p=0.001)

Summary

• The majority of graduating general surgery residents feel they are competent to perform a very limited # of surgical procedures.

• There is little consistency among general surgery residency graduates regarding which procedures are relevant to their practice.

1. Is the current clinical curriculum on target with general surgery graduates’ learning needs?

2. Should the clinical curriculum be better tailored to graduates’ future practice?

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LiteratureBlumenthal et al, JAMA, 2001“Overall (survey) data suggest that in 1998 residents…felt well...prepared for clinical practice. However, …the gaps still exist in the preparedness of physicians to manage the full range of patients, problems, and procedures they may confront at practitioners.”

Operative Experience Decreasing*

Kairys JC et al. JACS, 2008

Introduction

• Recent changes in general surgery and general surgery training have engendered questions about which procedures residents should become competent with by the end of their general surgery training.

• While procedural numbers are used as a proxy for competence with specific procedures, a program’s final declaration of competence is largely based on a cumulative faculty assessment of the resident’s overall competence.

Total Major Operations Decreasing*

Kairys JC et al. JACS, 2008