1. 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

2. 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.

3. 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

4. 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?

5. Subjects 20053200642007420085

6. 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)

7. Survey Instrument Each operation= two 4-point scales SAADSD “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)

8. 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.

9. 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).

10. Results Postgraduate Track# (n= 22) Surgical Oncology5 Minimally Invasive Surgery4 Cardiothoracic3 Colorectal2 Plastic Surgery2 Pediatric Surgery2 Breast1 Endocrine1 Non fellowship track2

11. 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

12. Most Relevant Operations Exploratory laparotomy with LOA Open chole Lap chole Ventral herniarepair Partial gastrectomy Enterectomy w/ anastomosis Colectomy, partial w/ anastomosis Colectomy, partial w/ coloproctostomy G-tube or J-tube inserts

13. 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

14. Least Competence Surgical treatment of NEC Orchiopexy Transhiatal esophagectomy Adrenalectomy Open AAA repair Endovascular AAA repair

15. 100% Respondents Perceived Competence 24% Operations (16 of 67)

16. 90% Respondents Perceived Competence Operations (34 of 67)

17. 50% Respondents Perceived Competence

18. 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)

19. 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.

20. 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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22. Literature Blumenthal 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.”

23. Operative Experience Decreasing* Kairys JC et al. JACS, 2008

24. 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.

25. Total Major Operations Decreasing* Kairys JC et al. JACS, 2008