Case numbers

[sponch]

Just an informal survey. Are you training at an academic or community program and what are the distribution of your cases on a year-to-year basis (only those done as surgeon or teaching assistant), e.g., R1 100, R2 250, R3 300, R4 400, R5 500.

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[dpmd]

I am at a community program and I had 217 cases my intern year, 176 my second year, 435 third year, and 134 so far this year (we have two elective rotations which due to a variety of reasons were nonoperative for me, some of my other rotations were on the light side for the OR as well, but the next two should make up some ground). Chief year is all about operating so should be more next year.

 

[SLUser11]

Just an informal survey. Are you training at an academic or community program and what are the distribution of your cases on a year-to-year basis (only those done as surgeon or teaching assistant), e.g., R1 100, R2 250, R3 300, R4 400, R5 500.

I can give my rough numbers from the acgme website, but I have to admit I'm a little behind logging cases.

Total defined category: 1,221 (285 Chief, 50 TA)

PGY-1: Total major 105, total cases: 451 (lots of lumps/bumps/endoscopy, lots of First assist, but I'm pretty strict about what I'll count as surgeon junior).

PGY-2: major 275, total cases: 575

PGY-3: major: 255, total: 480

PGY-4: major: 270, total: 432

PGY-5: Chief: 285, total: 395


It should be noted that case logs are a very emotional and subjective topic. Here's a link to a heated argument I had with some fellow SDNers a while back.

Here's another one specifically about intern year. Notably, I initially had 112 major cases as an intern, and when I re-ran the numbers, they dropped to 105...sometimes codes change and things that didn't count now do, and vice versa. That's a better reason than any to log everything you do. Trachs and anorectal stuff used to not count...now they do.😀

Anyway, while case numbers are important, they rely on your internal honor code, and they are simply one small aspect of your training. It's important to find balance, as I've said before.

 

[dpmd]

I don't do the things that some people advocate for boosting numbers (using A and B at the end of MRN so you can count the bowel resection and the control of liver bleeding in the same case, or using it to count the part of the case you did while someone else counts the case they did-although that is now allowed). I also tend to forget to grab stickers for some stuff (especially lines, but sometimes for counting cases too). The case log can be an indicator of issues (like if chiefs are graduating with just barely enough), but can also lead you astray (someone cheating the system who has more cases than me isn't necessarily better than me or anyone else with lower numbers).

 

[filter07]

What is the argument against erring on the side of more numbers? Don't hospitals look at this for granting privileges? Is this information that might be requested by a lawyer in any lawsuit? If I'm ever negotiating for a job or am on the witness stand, I'd want to have the caselogs backing me up.

 

[SLUser11]

The case log can be an indicator of issues (like if chiefs are graduating with just barely enough), but can also lead you astray (someone cheating the system who has more cases than me isn't necessarily better than me or anyone else with lower numbers).

What about residents who aren't cheating, but just have more cases?

That was the argument I had in the other thread....I still think volume is important, and I get nervous that places with low volume produce surgeons that are not adequately prepared for the real world (not your institution obviously as your numbers look good).

I agree with you that any resident "boosting numbers" is only cheating his/herself. I don't see the double resident phenomenon you described at my program, but it's probably because we're rarely double scrubbed, unless one resident is the TA and the other is the surgeon junior. Also, I cringe when I hear people are logging each piece of a case individually to turn it into multiple defined cases.

 

[dr.evil]

Log everything properly... and log everything. If you have to log multiple cases from a single operation, that's a sad statement for your program and you should tell that to people interviewing for your program.

I'm just telling you right now, volume is KING in practice. See and do as much as you can and go to a place that let's you operate from day one and all the time. You are never going to wish you would have done more floor work, or pre-op care, or post-op care so hopefully you will have done so much volume that you have seen almost everything that can be thrown your way.

My first few years I rarely, if ever, logged a first assist because they "don't count" so I couldn't have cared less about them. I just operated with the staff and enjoyed being in the O.R. That's a mistake when your out in practice. Bariatrics is one area that you should log everything...you never know when you are going to do bariatrics or assist someone or cover for someone and the hospital likes to see bariatric surgery experience somewhere logged. They love those ACGME case logs. Thoracic is another that I ended up doing quite a bit of and was happy that I logged first assist and surgeon numbers for all of those cases.

I have no clue what average numbers are but SLUser11's look pretty good to me as long as they are a wide variety.

 

[filter07]

What do you guys do/use to keep track of things you learned in different cases? I have some difficulty remembering how to do certain surgeries. Any tips for efficient, concise, and quick ways to remember how to do things? I could do 3 hernias in a row and get a good feel for the nuances by the 3rd one, but I tend to forget when I don't do one in a long time. I could use something to remind myself real quickly. I am also pretty paranoid that a particular case will be the last time I see one before I go off into practice, and that I won't be able to do x,y,z when I'm out of residency.

 

[Guile]

Thoracic is another that I ended up doing quite a bit of and was happy that I logged first assist and surgeon numbers for all of those cases.

You do thoracic in private practice? That's impressive. What cases do you do?

I have no clue what average numbers are but SLUser11's look pretty good to me as long as they are a wide variety.

Compared to other programs' graduating chiefs, he has an excellent case log. 1200+ and he's not even finished. Very impressive.

 

[Guile]

What do you guys do/use to keep track of things you learned in different cases? I have some difficulty remembering how to do certain surgeries. Any tips for efficient, concise, and quick ways to remember how to do things? I could do 3 hernias in a row and get a good feel for the nuances by the 3rd one, but I tend to forget when I don't do one in a long time. I could use something to remind myself real quickly. I am also pretty paranoid that a particular case will be the last time I see one before I go off into practice, and that I won't be able to do x,y,z when I'm out of residency.

A lot of my residents have a notebook (separate from their case logbook) where they draw diagrams, make notes about cases, the relevant basic science, make notes about what attendings like, etc. Then when they're back on that rotation, they can just refer to their book. This is definitely something I plan on doing.

 

[dpmd]

What about residents who aren't cheating, but just have more cases?

They are at the least going to be more comfortable than me I would guess, unless of course all the cases were really simple and straightforward. I think you can learn a lot from one clusterf*ck versus a bunch of easy ones of whatever you do.

I didn't realize why the first assist cases were important, but evidently you can get privileges for stuff you just first assisted in. Hopefully you would have some help the first time you attempt one.

 

[dr.evil]

I came out of residency and did 2 pulmonary lobectomies in the first 2 months with just me and the scrub and it was outstanding. I did a ton of VATS for recurrent PTX, empyema, decortications. Several thoracotomies for the same. Believe it or not, there still exists areas of this country where old school general surgery still exists and if you have the training, you will have an awesome practice with a huge breadth. You just have to get out of the big city. At that practice, general surgeons did all of the vascular, endovascular, thoracic, breast, thyroids/parathyroids, esophagectomies, whipples, trauma, laparoscopy, etc. I never felt for one day that I wasn't trained well enough to do any of the cases safely and properly (or I wouldn't have done them). It was better than residency. My partners were very supportive if I needed them for thoracic cases, or whipples (did 3 of those my first year out with my partner). I brought in a huge amount of laparoscopic experience that they did not have so I "assisted" them with paraesophageal hiatal hernias, lap nissens, and lap colons. They were still doing these open prior to the new kid getting there to help.

I moved a couple of years ago for family reasons and miss some of that stuff as I've narrowed my scope some. I still do everything but whipples/esophagectomies and limited my chest stuff to decortications/empyemas/pneumothorax as I'm at a smaller hospital.

I would think that a good volume would be at least 1000 cases in 5 years (I believe I had 1350 and got in trouble for too many). See and do everything. Your partners in the future will love you.

 

[SLUser11]

I have no clue what average numbers are but SLUser11's look pretty good to me as long as they are a wide variety.

Compared to other programs' graduating chiefs, he has an excellent case log. 1200+ and he's not even finished. Very impressive.

I think my case numbers are pretty average for a busy operative program. I am probably better than most about logging everything...notice that only about half of my cases count toward anything. I always thought it was funny that kidney transplants and several other relatively big cases don't count for major credit.

As far as remembering steps in an operation, preop preparation is important. I also think repetition is key, which is one of the reasons that volume is important.

I also think you have to do some of these cases alone, do them wrong, and then learn retrospectively (good judgment comes from experience, and experience comes from bad judgment). I've never tried to keep notes on individual cases because I feel I'm too busy for that, and I'd lose track.

I agree that complicated cases are important. We all love chip shots, but we need to do the difficult colons/gallbladders/livers, etc to appreciate how to troubleshoot when things don't go perfectly.

 

[ESU_MD]

Its good to see well trained general surgeons doing thoracic and vascular cases. Why not?
The key is just to not take on more than you can chew and make sure the LOCAL system supports you.

thats what its all about....

 

[ESU_MD]

Also, i forgot how much time i spent logging those cases in the acgme system trying to get the right codes, optimize etc.... its one of those things that seems so important at the time. jobs have asked me for my oplogs (cardiac) but you have to wonder how much they actually look at them...

 

[Buzz Me]

A lot of my residents have a notebook (separate from their case logbook) where they draw diagrams, make notes about cases, the relevant basic science, make notes about what attendings like, etc. Then when they're back on that rotation, they can just refer to their book. This is definitely something I plan on doing.

Exactly. I started doing this a few years ago and it's really helped me prepare for cases..."how does Attending X like to set up his R hepatectomies again?"

As for my cases, in a top-heavy program, I'm at around 950 major cases with 14 months left.

 

[JayDoc06]

As I have mentioned, it is crazy to suggest volume isn't important. I don't care what type of justifications you try to come up- volume is volume. Now, maybe giving up 75 of your 200 gallbladders for 25 Nissens/Hellers is reasonable. But, the more cases done, the better. Every case is different, which I have come to appreciate in my essentially attendingless 5th year.

If a program has residents double credit cases by altering MR #s that is a big red flag. Also, if you sign your case log after 5 years and you did this, you are lying. Something you definitely shouldn't feel comfortable doing.

Anyway, as of Tax Day:

PGY-1: 88
PGY-2: 286
PGY-3: 346
PGY-4: 509
PGY-5: 183 (Lots of TA and chief-run services)

Total Major 1382, TA 182, Endo 191, Who knows how many "minors"


As for quality and diversity:

Lap Complex: 125
Lap Basic: 190
Plastics: 23
Pediatric: 105
Thoracic 40
Trauma Op: 89 (don't know how accurate my recording is)
Vascular: 154
Pancreas: 31
Liver: 30
Abdomen: 389
Alimentary: 383
Endocrine: 35
Head and Neck: 116
Soft Tissue and Breast: 105

Got above totals off ACGME site.


A very interesting part of this website to look at is:
http://www.acgme.org/residentdatacol...al_reports.asp
scroll down a little ways and you can click a year to find aggregate data for all graduating chiefs that year. Gives you a good idea of what the average resident ends up doing over 5 years.
__________________

 

[Buzz Me]

Nice link, I'll have to check that out!

 

[SLUser11]

A very interesting part of this website to look at is:
http://www.acgme.org/residentdatacol...al_reports.asp
scroll down a little ways and you can click a year to find aggregate data for all graduating chiefs that year. Gives you a good idea of what the average resident ends up doing over 5 years.
__________________

The link didn't work for me. How do I get to it through the ACGME website?

ps Great OR numbers!

I thought it's pretty interesting to have a lap basic to lap complex ratio of 190:125.

Another question: After around 200 scopes, do you feel pretty comfortable doing them in practice? What do you think the magic number is? I would also like to know how many of us are doing independent scopes versus two-person scopes with staff pushing while the resident steers.

The reason I ask is that we have family practice residents in town who do 40-50 scopes (two-person), then feel ready to do them in practice, which I think is crazy....I learned almost nothing from my early intern year two-man scopes. It's just infinitely easier to master endoscopy doing it alone....

 

[dpmd]

I can't imagine feeling comfortable after doing only two man scopes. It took a while doing them on my own before I figured out how to make it work for me (have smaller hands so had to come up with a somewhat different method). I have done 77 on my own and feel like I could do it in practice but wouldn't reach the cecum every time (I learned some tricks from the GI guy I did most of them with, but sometimes he would take over. Redundant colons are my weak area).

Speaking of two man procedures, I wonder how prevalent the one handed chole is at other institutions. I am on a mission to get rid of it at my program. I think it is more difficult when you don't have both hands to triangulate with, and it doesn't really teach you how to do the procedure. I have heard of places where they use two hands, but the other hand is holding the camera which I would consider a problem as well.

 

[SLUser11]

I can't imagine feeling comfortable after doing only two man scopes.

Agreed. For the one-man scopes, I tend to do mostly left-hand steering, right hand pushing, but when I need both hands for the steering, I use my left pinky to hold/manipulate the scope about 5cm outside the anal canal. It works pretty well.

As for reaching the cecum, I'm with you. While the textbooks would say that the sigmoid is the hardest part, I think the right colon is the most difficult. I think it's important to have good help (i.e. people who splint the abdomen intelligently), know how to manipulate the scope clockwise/counterclockwise as you remove your loop, and knowing when to give up and switch the patient from left lateral to supine/right lateral.

For the lap choles, I think doing them completely alone, i.e. without staff or a junior resident, is key to true troubleshooting. When I do gallbladders without intelligent help, I will prop the right lateral port (GB fundus) to the drapes with 2 hemostats, have the scrub tech run the camera (which can be painful), and work with a peon in the left hand and hook electrocautery in the right.

When I walk new interns through a gallbladder, I typically have them use their left hand to run camera. If a student is there, then the intern's left hand is reserved for sterile high-fives. More experienced interns and anyone beyond that are forced to operate with both hands whenever I'm in charge.

 

[dpmd]

When I walk new interns through a gallbladder, I typically have them use their left hand to run camera. If a student is there, then the intern's left hand is reserved for sterile high-fives.

We don't initiate people with one hand during appys anymore (the right upper quadrant port site variation on the lap appy is a holdover from when they did make people do it one handed). Why do it with a chole? I feel like it is harder to do it when your left hand is doing nothing.

 

[Smurfette]

We don't initiate people with one hand during appys anymore (the right upper quadrant port site variation on the lap appy is a holdover from when they did make people do it one handed). Why do it with a chole? I feel like it is harder to do it when your left hand is doing nothing.

Interesting. I'm comfortable doing choles either holding the camera or with my left hand free (due to having students scrubbed in during residency---they usually held the camera)....however, I am short and cannot reach over to manipulate the right lateral instrument very easily in a big patient (and I always need a step for a lap chole to start with). Was very happy that all the surg assists in my current hospital are experienced with lap choles and take direction well. But I have had to walk around the table to adjust that grasper with an inexperienced assistant (i.e. med student) before....and then clamp it down with a towel clip or curved 6 while I return to the left side and manipulate the other grasper (middle port) for the rest of the case.

For scopes, I do what SLU is describing (1-man technique) but use my right pinkie/ring finger to hold it in place for two handed steering when necessary. It took me a while to get my own technique due to my small hand size (size 5 1/2 glove), but I like to be able to feel the resistance when advancing and rotating the scope. Worked once with an attending who wanted me to do the two man technique and hated it.

 

[Guile]

A very interesting part of this website to look at is:
http://www.acgme.org/residentdatacol...al_reports.asp
scroll down a little ways and you can click a year to find aggregate data for all graduating chiefs that year. Gives you a good idea of what the average resident ends up doing over 5 years.
__________________

Could you repost that link? It was truncated and doesn't work any longer. Thanks.

Incredible numbers you have. I especially noticed your big pancreas and liver numbers. You must feel good going into fellowship.

 

[dienekes88]

Could you repost that link? It was truncated and doesn't work any longer. Thanks.

Incredible numbers you have. I especially noticed your big pancreas and liver numbers. You must feel good going into fellowship.

acgme.org/residentdatacollection/documentation/statistical_reports.asp

 

[SLUser11]

We don't initiate people with one hand during appys anymore (the right upper quadrant port site variation on the lap appy is a holdover from when they did make people do it one handed). Why do it with a chole? I feel like it is harder to do it when your left hand is doing nothing.

While Appendectomies and cholecystectomies are both "simple laparoscopy," they are quite different. The exposure for the lap chole is more complex. When interns are starting out, I don't feel like they have the skillset to appropriately retract the gallbladder with the left hand, which is a more dynamic process than lifting anterior on the base of the appendix.

 

[JayDoc06]

Sorry for delay in responding.

I think the link dienekes88 posted should work. If not, just go to ACGME home page, scroll down and click "Case log statistical report", then scroll down and pick whichever specialty you are interested in, no "General Surgery" available, but "Surgery" instead. BTW, this is not a program breakdown but rather averages, standard deviations and maximums for entire classes of graduating chiefs nationally. I think it is interesting that numbers, on my superficial glance, appear essentially unchanged over a decade, even with work hour rules.

SLUser- well over half of those are upper scopes. I am by no means polypectomy facile, but I intentionalyl found other things to do instead of C Scope due to my plans to do a colorectal fellowship, where I will get plenty. My classmates and I have discussed this, they feel pretty good about solo scoping. Everyone should be aware that there is push to raise the required scopes to get credentials (of course pressure is from GI...) This number (forgot what it actually is) will be hard, though not impossible, for many general surgery programs to get. We're trying to figure out ways to increase our C-scopes to keep ahead of these anticipated change.

Happy Derby Week

 

[dr.evil]

Just looked at those numbers. I was actually shocked how low they were. I assumed most programs logged over 1000 major cases in 5 years but apparently once you get to 1100, you are in the 90th percentile in numbers. I guess around 900 is average on those sheets.

Also, if the average number of EGDs is 25 and colonoscopies is 35 as indicated, that's not nearly enough to recognize pathology. The GI guys are right on this one. Volume will not only get you adept at reaching the cecum and intubating the ileocecal valve, it will expose you to more types of pathology such as serrated adenomas or various types of colitis.

Get volume when you train. That's all I want to say to people. It's only 5 years. Do every single possible procedure you can get your hands on, no matter how small it may seem or how beneath you it may be.

In practice, I routinely do Lap choles with a single scrub. She drives the camera and holds the instrument on the fundus. I grab what I want/need off the mayo as I'm pretty standard. Don't even think about it any more. It's various scrubs too.

Graduated responsibility for the interns to go from a one hand to a two hand technique is very reasonable. Some will progress rapidly, some won't. But if you're making a 2nd year use one hand technique, they need more operative experience in their intern year. My opinion of course.

 

[Buzz Me]

I think it is interesting that numbers, on my superficial glance, appear essentially unchanged over a decade, even with work hour rules.

I log summaries of all the articles I read so was reminded of this one...

Check out:

Simien C et al, Resident operative experience in general surgery, plastic surgery, and urology 5 years after implementation of the ACGME duty hour policy, Ann Surg 2010; 252: 383-9

*Compared graduates from 2002-2003 (before 80-hr workweek) and 2007-2008 (after)
*Tracked changes in average case numbers for various defined categories
*Vascular 104 to 86
*Plastics 15 to 13
*Endoscopy 82 to 77
*Thoracic 37 to 35
*H&N 54 to 52
*SST 52 to 51
*Abd 136 to 135
*Alimentary 142 to 142
*Liver 12 to 12
*Pancreas 10 to 12
*Endocrine 28 to 33
*Lap basic 112 to 132
*Lap complex 41 to 62

 

[Svidrillion]

Sorry for delay in responding.

I think the link dienekes88 posted should work. If not, just go to ACGME home page, scroll down and click "Case log statistical report", then scroll down and pick whichever specialty you are interested in, no "General Surgery" available, but "Surgery" instead. BTW, this is not a program breakdown but rather averages, standard deviations and maximums for entire classes of graduating chiefs nationally.

Do they publish the data for graduating chiefs by program?

 

[Buzz Me]

Do they publish the data for graduating chiefs by program?

You mean, is there a nice centralized ranking of all Gen Surg residency programs where one can compare stats (like case numbers), etc. to aid in making the rank order list?

Nope, unfortunately not. You just have to ask about case numbers during interviews, and then look at them critically.

 

[Svidrillion]

That's unfortunate. They should publish case numbers like they do board pass rates.

 

[Buzz Me]

That's unfortunate. They should publish case numbers like they do board pass rates.

But one is much more objective than the other.