AT WSA 2016

CORONADO, CALIF. (FRONTLINE MEDICAL NEWS) – Creation of a surgical chief resident service meant to increase resident autonomy and provide continuity of patient care with appropriate faculty supervision has been successful, results from a small single-center study showed.

“Providing opportunities for autonomy to bolster the development of independence and confidence during surgery residency remains among the most pronounced challenges of the current training paradigm,” Benjamin T. Jarman, MD, said at the annual meeting of the Western Surgical Association. “Prior to 2011, our graduating surgery residents reported a lack of perceived autonomy during their training and a need to improve practice management skills. To be clear, they consistently felt confident in their surgical abilities, but they did not sense that they were routinely engaged in directing all phases of care.”

Dr. Jarman of the department of surgery at Gundersen Health System La Crosse, Wisc., noted that both concerns and reassurances regarding the confidence of general surgery residents have been raised. One survey of residents midway through their academic year noted anticipated challenges in confidence ( Arch Surg. 2011;146[8]:907-14 ). A separate survey of fellowship directors noted deficiencies in those who pursued fellowship training ( Ann Surg. 2013;258[3]:440-9 ), while a subsequent survey of surgery residency graduates and senior surgeons noted remarkable discrepancies between perceptions of confidence and ability ( J Am Coll Surg. 2014;218[5]:1063-72 ). On a more positive note, most graduating general surgery residents reported confidence in entering general surgery practice, especially if they had done more than 950 operations ( J Am Coll Surg. 2014;218[4]:695-703 ). A separate study reported on a survey of surgeons in their first year of practice, and 94% expressed confidence in their ability to operate ( Ann Surg. 2015;262[3]:449-55 ). Another survey reported a dire need for inclusion of practice management skills in residency training ( Surgery. 2015;2015;158[3]:773-6 ). Only one-third of residency program directors who responded to the survey reported the inclusion of such curriculum.

In an effort to provide chief surgery residents with increased autonomy and full-spectrum continuity of patient care, Dr. Jarman and his associates initiated a chief resident service (CRS) in January of 2011. It was designed as an independent service with call responsibilities, office hours, operative scheduling, procedural coding, and endoscopy time. “We constructed a weekly schedule to be consistent with the practice of a general surgeon in the first year after residency,” Dr. Jarman explained. “We also added administrative time for research, patient coordination, and completion of records. Each class of chief residents was educated about these responsibilities as a group, and individual sit-down sessions occurred before they started the rotation. Expectations were made clear, and the importance of clear communication was stressed. The service was geared to provide excellent exposure to practice management skills.” Members of teaching faculty were assigned to each episode of patient care to meet all supervision guidelines and patients were educated accordingly. “The primary difference of and key to this service is that of patient continuity with the chief resident from preoperative assessment to postoperative care,” he said. “So our faculty had to adapt to the transient role that our residents are accustomed to.”

Dr. Jarman presented results from a study of nine surgeons who completed the CRS between January 2011 and June 2014. Total operative volume during residency was assessed in addition to select procedures for the chief service experience versus the residents’ first year of clinical practice. Residents who pursued fellowship training submitted their operative logs from their first year postfellowship. Graduates were surveyed to assess their current clinical practice, satisfaction with the chief service, and whether they perceived a correlation of the CRS with their clinical practice. Patient evaluations were reviewed as well. The researchers focused on the following procedures for comparison: laparoscopic appendectomy, laparoscopic cholecystectomy, colectomy, ventral/incisional hernia repair, inguinal hernia repair, upper endoscopy, and lower endoscopy.

All nine chief surgery residents completed the chief service and completed case logs. “The first three residents to graduate after implementation of the service spent 2 months each on the rotation, while subsequent graduates spent between 4 and 6 months, depending on how many chiefs we had in a given year,” Dr. Jarman said. The median total case volume was 1,101 during the 5-year residency, 92 during the CRS, and 299 during the first year of practice. When the researchers evaluated overall median case volumes, lower endoscopy volumes were higher during the first year of practice, compared with during the CRS (a median of 71 vs. 10 cases, respectively); otherwise there were similar case volumes across the other procedures selected for evaluation. Next, they determined the mean case volumes by month for the selected general surgical procedures and found similar case volumes with the exception of colectomy, which was more commonly performed during the CRS, compared with during the first year of practice (a mean of 1 vs. 0.4 cases; P=0.016).

All nine graduates completed an electronic survey relaying details about their current practice and degree of satisfaction with the CRS; 100% reported being “very satisfied” with their CRS, and 100% found it “very beneficial” to their practice. In addition, 56% said that their cases on the CRS were “somewhat similar” to their current practice, while 44% said that their cases were “very similar” to their current practice.

Since the inception of the CRS, Dr. Jarman and his associates have made several adjustments to the CRS, including incorporation of endoscopy time, adjusted office hours, the required presence of surgery assistants in the OR, and requiring fourth-year residents to attend the ACS Leadership Conference in preparation for the CRS role. He acknowledged certain limitations of the study, including its small sample size and the fact that its participants had variable clinical experience. “But we’re on the ground running,” Dr. Jarman said of the CRS. “The chief residents are wide-eyed and very engaged in this process, and the impact on their development and respect for all the caveats of independent practice has been significant. The strengths of the service include exposure to practice management skills, whole-spectrum clinical care for a single resident at a time, and operative experience which correlates to that experience of a first-year surgeon.” He reported having no financial disclosures.