Cases per month?

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lildave2586

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What's a good number for cases on a per month basis for a resident? At my school residents will do ~50 per month (usually split between two residents) at a particular site. How does this caseload compare to other institutions? How many should I be looking for in a training program?

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It's not the number of cases, but the diversity of cases and level of involvement that really matter. Also, each "case" may have multiple procedures that are coded in their logbooks. i.e. a typical laryngectomy may code 1) laryngectomy 2) bilateral necks, 3) CP myotomy, 4) pec flap 5) skin graft, etc...
 
Agree with Leforte.

Also, the number of cases can be a little deceiving. For example 1 bilateral FESS could be recorded as 8 "cases." i.e. B maxillary, ethmoids, frontals, sphenoids. Some programs with busy peds hospitals could have residents logging hundreds of tubes and tonsils. Once you do 10 or 15 of either, you know how to do the procedure.

Some procedures may be logged as resident surgeon even though the resident was just retracting or even watching. This is especially true for otologic or cosmetic facial plastic procedures. Ask at your interviews (tactfully) about the true nature of the ear and plastics surgical experience of the residents.

Most programs will provide case logs of previous graduating chiefs for interviewees to peruse as well.
 
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I did just over 3100 cases in my residency where I listed myself as primary (I'm sure not all of these were truly primary, but I bet I fudged that on less than 5%) which boils down to about 64.5/month. We had a heavy peds experience, though, so I did 400 or so tubes and tonsils on my jr 3 month rotation at the children's hospital (133/month). It was not unusual to do 17 cases in a single day running 2 rooms with one attending.

Although I agree with my colleagues above that volume isn't everything, it is definitely a key ingredient. Residency is your chance to make mistakes. I can't tell you how hard it is to see my older colleagues in the community try to learn techniques that I developed as a resident. For example, the 50yo+ guys trying to learn modern sinus techniques doesn't translate well in a significant number. Untrained docs trying to perform minimally invasive thyroid surgery in under 90 minutes or even within 3 hrs for some of them. Guys that did traditional septos for the last 20 yrs trying to figure out how to do it endoscopically. That sort of thing. Moreover, you can't beat experience. You just can't. You can learn medicine by reading a book. You can learn how to treat sinus disease, dizziness, ear infections, reflux, etc by sitting on your couch. But you can't learn how to do surgery that way. There's just no comparison.

Although I agree with Oto-HNS that you know how to do a surgery after 15-20 cases, I would disagree with others who have the idea that once you do 15-20 sinus cases, you've got it. Certainly you can be more comfortable, but I would not want to graduate having done only 15 maxillary antrostomies. I still learn in almost every case I do and I'm up to about 2500 sinus cases now (not codes, but patients). I think the same can be said for ear surgery, H&N, and even laryngology.

I would rank case volume as primary surgeon as the number 1 or 2 in terms of where to go for residency. Overall perceived quality would be the other complimentary criteria. A distant 3rd for me is location. But that's for me--a guy who knew he wanted to be a non-academician. I wanted to be the best ENT in whatever city I settled. I thrived on my surgery skills over my lacking intellectual prowess. I guarantee I wasn't the smartest ENT in my program and am not the smartest in my community, but I bet most would say I have the best hands (at least in the realm of what I do). It doesn't take long for the OR staff and anesthesiologists to get word out about who is great in the OR and who isn't. In the ENT world, we need a balance of brains and skill to thrive. Hopefully my lack of functional IQ is made up by quality OR work which I owe in large part due to my residency surgical volume.
 
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How do you know if a program has a good balance of autonomy vs. intraoperative instruction? At my school it seems like every time I'm with the residents, they are doing the cases by themselves (usually PGY4s, sometimes 3s depending on the case) with the chief helping when they need it. The attending will pop his/her head in take a quick look and bolt. This is usually dependent on the service (it seems like attendings are the primary surgeon at the private hospitals). Is this pretty standard?
 
How do you know if a program has a good balance of autonomy vs. intraoperative instruction? At my school it seems like every time I'm with the residents, they are doing the cases by themselves (usually PGY4s, sometimes 3s depending on the case) with the chief helping when they need it. The attending will pop his/her head in take a quick look and bolt. This is usually dependent on the service (it seems like attendings are the primary surgeon at the private hospitals). Is this pretty standard?

Asking the residents is the only way to know if there is a balance. My program had some really good balance. At Children's we were closely supervised--one of my attendings even looked through the teaching scope during tubes after having done a hundred. Just her thing. Same program, different hospital, complete autonomy. The attending walked in to sign the chart, then walked out--didn't even look at the patient even for big head and neck or ear cases. Same program, University Hospital, attendings would let you do as much of the case autonomously as they felt you could. They'd scrub out but stay in the room. Sometimes, they'd just hold sticks but stay scrubbed in. Sometimes, they'd do the case. Just depended on their comfort level with your comfort level and skill.

I think I had a pretty good mix that served me well and would look for the same thing if I was applying. You can't get that information from the attendings, though, only the residents can answer that one or SubI's who were there to witness it.
 
I pretty much agree with resxn here. There's also a distinction I think between doing enough of a particular case to be competent vs. doing enough to be a true expert at it. How many cases is "enough" is probably different for every different person. For tubes and tonsils, 10-15 is enough to be competent in my opinion for most residents. For sinus cases, I'd agree that number is probably higher.
I did notice for my own self that when I went back to doing tonsillectomies as an attending, they tended to go much more smoothly I think because of my overall better surgical technique from doing head and neck cases as a senior resident.
Overall, though, I do agree that more is better, but at some point you get diminishing returns, i.e. is 1000 tubes really that much better than 100 tubes?

I did just over 3100 cases in my residency where I listed myself as primary (I'm sure not all of these were truly primary, but I bet I fudged that on less than 5%) which boils down to about 64.5/month. We had a heavy peds experience, though, so I did 400 or so tubes and tonsils on my jr 3 month rotation at the children's hospital (133/month). It was not unusual to do 17 cases in a single day running 2 rooms with one attending.

Although I agree with my colleagues above that volume isn't everything, it is definitely a key ingredient. Residency is your chance to make mistakes. I can't tell you how hard it is to see my older colleagues in the community try to learn techniques that I developed as a resident. For example, the 50yo+ guys trying to learn modern sinus techniques doesn't translate well in a significant number. Untrained docs trying to perform minimally invasive thyroid surgery in under 90 minutes or even within 3 hrs for some of them. Guys that did traditional septos for the last 20 yrs trying to figure out how to do it endoscopically. That sort of thing. Moreover, you can't beat experience. You just can't. You can learn medicine by reading a book. You can learn how to treat sinus disease, dizziness, ear infections, reflux, etc by sitting on your couch. But you can't learn how to do surgery that way. There's just no comparison.

Although I agree with Oto-HNS that you know how to do a surgery after 15-20 cases, I would disagree with others who have the idea that once you do 15-20 sinus cases, you've got it. Certainly you can be more comfortable, but I would not want to graduate having done only 15 maxillary antrostomies. I still learn in almost every case I do and I'm up to about 2500 sinus cases now (not codes, but patients). I think the same can be said for ear surgery, H&N, and even laryngology.

I would rank case volume as primary surgeon as the number 1 or 2 in terms of where to go for residency. Overall perceived quality would be the other complimentary criteria. A distant 3rd for me is location. But that's for me--a guy who knew he wanted to be a non-academician. I wanted to be the best ENT in whatever city I settled. I thrived on my surgery skills over my lacking intellectual prowess. I guarantee I wasn't the smartest ENT in my program and am not the smartest in my community, but I bet most would say I have the best hands (at least in the realm of what I do). It doesn't take long for the OR staff and anesthesiologists to get word out about who is great in the OR and who isn't. In the ENT world, we need a balance of brains and skill to thrive. Hopefully my lack of functional IQ is made up by quality OR work which I owe in large part due to my residency surgical volume.
 
It seems like the residents that I have been working with learn from each other a lot. For example, the PGY3,4 is teaching the PGY2 how to do a trach. There really isn't much attending presence from what I've seen. I'm wondering if this would lead to less development with less scrutiny compared with programs where an attending is always there watching every move you make. Any thoughts on this?
 
It seems like the residents that I have been working with learn from each other a lot. For example, the PGY3,4 is teaching the PGY2 how to do a trach. There really isn't much attending presence from what I've seen. I'm wondering if this would lead to less development with less scrutiny compared with programs where an attending is always there watching every move you make. Any thoughts on this?

Again, it depends. If there's a high surgical volume and a senior resident is teaching a jr through the case, no big deal. If it's like that at every hospital in the program, then I would argue that there is a loss of quality training compared to the programs where there is a mix of attending oversight.

For a time, I was in the military. When I went to one of the bases as a medical student to do a subI I saw an R4 take a tonsil from an R3--the R2 didn't even have a shot. This was not uncommon and it was a shock to me as rarely did anyone but an R2 do these cases at any other program. They clearly lacked volume although they had great attending oversight. I will say that academically they were unreal--everyone in their program finished at >90% on the in-service but that's because every Th was academic day--no patients, no OR. They just studied. Very book smart, but poorly lacking in surgical skill.

There's a need for balance.
 
Again, it depends. If there's a high surgical volume and a senior resident is teaching a jr through the case, no big deal. If it's like that at every hospital in the program, then I would argue that there is a loss of quality training compared to the programs where there is a mix of attending oversight.

For a time, I was in the military. When I went to one of the bases as a medical student to do a subI I saw an R4 take a tonsil from an R3--the R2 didn't even have a shot. This was not uncommon and it was a shock to me as rarely did anyone but an R2 do these cases at any other program. They clearly lacked volume although they had great attending oversight. I will say that academically they were unreal--everyone in their program finished at >90% on the in-service but that's because every Th was academic day--no patients, no OR. They just studied. Very book smart, but poorly lacking in surgical skill.

There's a need for balance.

Thanks for the reply. Are there programs out there today that have volumes such as you've described above? I suppose the only way to know is to ask the residents at an interview?
 
of course there are; and, yes, ask. I would bet it's more the rule than the exception that programs have a good mix.
 
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