T. N. Ballard1, W. Pozehl2, T. R. Grenda1, M. S. Daskin2, J. Seagull3, A. M. Cohn2,4, S. J. Kasten1, R. M. Reddy1 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Department Of Industrial And Operations Engineering,Ann Arbor, MI, USA 3University Of Michigan Medical School,Ann Arbor, MI, USA 4University Of Michigan,Center For Healthcare Engineering And Patient Safety,Ann Arbor, MI, USA
Introduction: On July 1, 2014, the new Accreditation Council for Graduate Medical Education (ACGME) operative minimum requirements for plastic surgery residents became effective. Under the updated guidelines, the resident “assistant” option is no longer used, and up to two residents can count a case as “surgeon” if each is present for and participates in all of the critical portions of the operation. Given that specific operative case arrival/frequency and resident distribution are not equitable, we sought to assess the applicability of a case distribution simulation model to determine the threshold case volume required to certify plastic surgery residents using the new guidelines. The treatment of occlusal injuries was utilized as an example procedure.
Methods: A novel computer model was created to simulate annual case distribution based on annual case volume, number of trainees, and rotation length, and assess for a program’s ability to train all residents each year. The simulator varies the annual volume based on historical data provided (above and below the mean). Single institution occlusal injury treatment data (2010-2013) were used to simulate case distribution for 10,000 “simulated” years to indicate the frequency of one or more senior residents achieving the minimum number of cases during their final two years of training.
Results: The illustrated program currently has three residents per year, and the average number of occlusal injuries treated was 27.3 ± 6.6 over a four-year period. The ACGME requires all plastic surgery residents to treat at least eight occlusal injuries during training. If the final two years of a resident’s training are simulated, with up to two residents able to count each case and each resident having equal access to all cases, all three chiefs would meet the requirement for occlusal injury treatment 98.2% of the time. If the program expands to four residents, the likelihood of all residents meeting requirements decreases to 87.1%.The minimum number of cases per year necessary to certify three and four residents 100% of the time is 28 and 29, respectively.
Conclusion: Under the new ACGME guidelines for plastic surgery, residents log only “surgeon” cases, and up to two residents may count each case. However, the number of annual cases needed each year to fulfill requirements is greater than simply the number of residents multiplied by the number of required cases (i.e., 3×8 ≠24), due to unpredictable and inequitable case occurrence. The simulator enables residency programs to analyze the impact of the new operative requirements on the ability to certify current residents and the effect of expanding the number of residents. The broad applicability of such a model is just being realized.