N. A. O’Neill1, R. G. Conway1, C. T. Laird1, K. M. Lumpkins1, S. M. Kavic1, E. D. Strauch1 1University Of Maryland,Surgery,Baltimore, MD, USA
Introduction: General surgery training is experience based, and the transition from novice to expert occurs after optimizing surgical case volume. Here we explored the trends in graduating general surgery residents’ reported cases for pediatric surgery.
Methods: Using the Accreditation Council of Graduate Medical Education’s (ACGME) published case log statistical reports for general surgery residents, the mean major pediatric surgery cases, pediatric major subcategory cases, and total major cases logged for each academic year’s graduating class were reviewed from 2000 – 2017. Statistical analysis was performed using linear regression with SAS.
Results: The total number of general surgery residents in the United States has linearly increased from 989 residents in 2000 to 1211 residents in 2017 (R2: 0.89, p <0.001), as has the number of pediatric surgery fellows taking the qualifying board examination from 34 in 2000 to 56 in 2017 (R2: 0.70, p<0.001). Junior residents logged 93.7% (SD 0.9%) of pediatric surgery cases. The average major pediatric surgery cases logged by graduating general surgery residents are steadily declining from a peak of 42 (4.5% of total major cases) in 2003 to 26 (2.6%) in 2017 (R2: 0.92, p <0.001; Figure 1). The most commonly logged pediatric case subcategory each year is “inguinal/umbilical herniorrhaphy.” Subcategory “repair omphalocele/ gastroschisis” (+21%, R2: 0.64) and “anti-reflux procedure – laparoscopic” (+579%, R2: 0.86) have increased over the study period, but both “branchial cleft/thyroglossal duct” (-37%, R2: 0.85) and “anti-reflux procedure – open” (-92%, R2: 0.94) have decreased. Since 2003, the reported major pediatric cases are decreasing with a rate of 1 case every academic year. If this rate continues, residents graduating in 2023 will be logging only 20 pediatric surgery cases, which is the minimum requirement by the ACGME.
Conclusion: In the past 17 years, there has been a slow, persistent decline in pediatric surgery cases performed by graduating general surgery residents. Just as in the fable of a frog in water that is slowly boiled, if this trend continues, we risk a critical erosion of pediatric experience for general surgery residents. While the exact cause is unknown, the experience gap may lead to a vicious cycle where attendings and fellows are performing more cases with the focus on protecting outcomes and institutional reputation, which in turn decreases the operating opportunities for their trainees.
