Does higher volume always = better surgical residency?

[knock0ut]

Been seeing a lot of posts about "this surgical program doesn't have high volume, so not good training." Are the costs of going to the highest volume surgical program (less time to prepare for cases, more burnout, others?) worth the benefits of seeing and doing more surgeries? Could relatively lower volume (but still getting in all of the required numbers obviously) actually be beneficial because you have more time to prepare for cases, more motivation to learn due to less burnout, etc? Basically I'm wondering if you can learn better by having somewhat fewer cases but having more time and more of yourself to put into those cases.

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[LucidSplash]

Been seeing a lot of posts about "this surgical program doesn't have high volume, so not good training." Are the costs of going to the highest volume surgical program (less time to prepare for cases, more burnout, others?) worth the benefits of seeing and doing more surgeries? Could relatively lower volume (but still getting in all of the required numbers obviously) actually be beneficial because you have more time to prepare for cases, more motivation to learn due to less burnout, etc?

High volume does not necessarily equal burnout or not enough time to prepare for cases. Volume that only gives you the bare minimum of required cases is not going to be enough to train you adequately. So no, lower volume would not be beneficial in the ways you suggest.

 

[knock0ut]

High volume does not necessarily equal burnout or not enough time to prepare for cases. Volume that only gives you the bare minimum of required cases is not going to be enough to train you adequately. So no, lower volume would not be beneficial in the ways you suggest.

Thanks. A program I was looking into had relatively lower overall volume, but also stated that they have had a 100% board pass rate for over 20 years. What do I make of that? Does that board pass rate mean their volume is high enough, or do board pass rates not necessarily correlate with how good your training was and/or how good of a surgeon you will be?

 

[LucidSplash]

Board pass rate means they have enough knowledge to take the written and oral boards, which is a good thing. It does not necessarily correlate with good operative experience. You need enough operative time to be independent when you leave residency. Even if you choose to do a fellowship, you should be be prepared to go into private practice general surgery.

I should also include that high volume doesn't necessarily mean you are getting enough autonomy to be independent when you graduate. You need to query the chiefs on their experience, if they feel prepared to operate independently, how much of the case they are getting to do, if they are taking junior residents through cases or if the attending is still using them as an assist. Volume is only helpful if there is appropriate graduated autonomy.

 

[Gate Closed]

Thanks. A program I was looking into had relatively lower overall volume, but also stated that they have had a 100% board pass rate for over 20 years. What do I make of that? Does that board pass rate mean their volume is high enough, or do board pass rates not necessarily correlate with how good your training was and/or how good of a surgeon you will be?

I really doubt that there is a program with "100% board pass rate for over 20 years" (assuming first attempt only).

 

[Localnative]

Been seeing a lot of posts about "this surgical program doesn't have high volume, so not good training." Are the costs of going to the highest volume surgical program (less time to prepare for cases, more burnout, others?) worth the benefits of seeing and doing more surgeries? Could relatively lower volume (but still getting in all of the required numbers obviously) actually be beneficial because you have more time to prepare for cases, more motivation to learn due to less burnout, etc? Basically I'm wondering if you can learn better by having somewhat fewer cases but having more time and more of yourself to put into those cases.

volume, no
more autonomy = greater preparedness post residency = better but not necessarily a "nicer" program.
went to a resident run hospital for training. painful yes, malignant yes. now i'm in practice X 7 yrs- looking back, I'm glad I went through that boot camp.

 

[OnePunchBiopsy]

Thanks. A program I was looking into had relatively lower overall volume, but also stated that they have had a 100% board pass rate for over 20 years. What do I make of that? Does that board pass rate mean their volume is high enough, or do board pass rates not necessarily correlate with how good your training was and/or how good of a surgeon you will be?

Dallas Methodist?

 

[DrSnips]

I really doubt that there is a program with "100% board pass rate for over 20 years" (assuming first attempt only).

Unless they mean 100% of people who were given over 20 years to pass the boards were successful.

 

[mimelim]

I agree with @LucidSplash and to add a few thoughts...

When considering a residency, two things matter above all else. #1 Pathology, #2 Mentorship. You need both in order to graduate from the program and be in a well trained physician. This is true in ALL specialties, not just surgery. In surgery, pathology means cases. Both operative and non-operative. You have to see a large volume of patients over an extended period of time. This is not just about technical skills. This is about acquiring experience to be a safe and effective surgeon. Yes, you need to do enough operations to be technically competent, but you also need to learn which operations to pick when there are options and even more importantly when NOT to operate. But, pathology alone is not enough. You need surgeon mentorship in order to excel. You need staff surgeons to teach you how to manage the pathology, pre-op, in the OR and post-op. If you don't have staff willing to teach and mentor you, you will not learn. If you don't have staff willing to sacrifice their time and energy to train you, you will not learn. Part of that means a certain amount of level appropriate autonomy. If you don't get increasing amount of rope to work with, you will not progress nearly as much.

It is also important to note that not all volume is equal. Excessive service requirements from busy, but poorly mentored services can really kill a residency. Sometimes it can be a trauma service, but more often than not it is a super private, busy niche service that simply absorbs resident time, but does not afford them training.

At the end of the day, volume is not everything, but it is a huge component of your training. There is certainly a limit and there are malignant programs out there, but you need a lot of cases to really get ramped up for going into practice. ACGME required numbers aren't the benchmark. They are the minimum. How well trained you are at the end of the day is the benchmark. Can you walk out of the program and practice surgery. Most chiefs that I know will say that residency feels too short sometimes because they realize how much they want to learn before they graduate and they enjoy how much they are learning by doing lots and lots of cases.

Personally, I'm a PGY-5. Since the start of May (3 days), I've done 13 cases. 2 CEA, 1 bypass, 1 EVARs, 3 lower ext angios, 5 dialysis accesses, 1 BKA. The first 4 cases are the 'major' cases that ACGME tracks, but I honestly got a ton out of the angios, access cases and the amputation because I did 80%+ of them without staff in the room. The 20% that they were around was intellectual, not technical. Decision checking, thought process verification, etc. You need sufficient volume that your staff feel comfortable with you doing these operations without them. You can't get that with minimal numbers and certainly can't get that without a ton of smaller cases in between the tracked ones.

 

[mmmcdowe]

Been seeing a lot of posts about "this surgical program doesn't have high volume, so not good training." Are the costs of going to the highest volume surgical program (less time to prepare for cases, more burnout, others?) worth the benefits of seeing and doing more surgeries? Could relatively lower volume (but still getting in all of the required numbers obviously) actually be beneficial because you have more time to prepare for cases, more motivation to learn due to less burnout, etc? Basically I'm wondering if you can learn better by having somewhat fewer cases but having more time and more of yourself to put into those cases.

There is always a price. Every program has pros and cons, you cant log 2000+ cases plus write 100+ papers plus sleep 8 hours a night. One major difference from a high vs low case load program is the order of your education. I went to a med school whos residency was very academic. there you learn a lot about the why early on and the how as a senior resident. meaning they had incredible theoretical knowledge of whyto do surgeries and when, but the actual hands on learning came later. At my program the early years are heavily focused on the how and it isn't until you're call responsibilities lighten and you enter your elective time and chief year that you get a lot of the more technical nuances of planning and patient selection.

Thanks. A program I was looking into had relatively lower overall volume, but also stated that they have had a 100% board pass rate for over 20 years. What do I make of that? Does that board pass rate mean their volume is high enough, or do board pass rates not necessarily correlate with how good your training was and/or how good of a surgeon you will be?

FWIW boards are easy to pass hard to excel in. I passed my boards this year as a PGY3 by merely doing 1000 practice questions over a 6 month period. I didn't do well by any means, but it just goes to show you that passing is a low bar. I hear the oral boards are more clinically relevant, but the written boards at least are only minimally related to my clinical acumen.

Board pass rate means they have enough knowledge to take the written and oral boards, which is a good thing. It does not necessarily correlate with good operative experience. You need enough operative time to be independent when you leave residency. Even if you choose to do a fellowship, you should be be prepared to go into private practice general surgery.


I should also include that high volume doesn't necessarily mean you are getting enough autonomy to be independent when you graduate. You need to query the chiefs on their experience, if they feel prepared to operate independently, how much of the case they are getting to do, if they are taking junior residents through cases or if the attending is still using them as an assist. Volume is only helpful if there is appropriate graduated autonomy.

Agreed, the traditional knowledge in my field is that written board scores are inversely proportional to operative volume. When I was choosing residencies I had strong reservations about not getting the best possible operative training. I am definitely applying for fellowships, but I want to be a fellow that teaches residents not a fellow learning from them.

 

[BeddingfieldMD]

The question of volume and case diversity actually affects all residency types--not just surgical ones.

Somewhere far away in the Land of Oz, there is a residency program with the ideal volume and diversity of patients and procedures. Residents see virtually everything they will ever encounter in their future careers. They gain more than enough exposure to become experts in their fields. But they have the perfect amount of time to prepare--and maintain an exquisite work-life balance. Every minute on call is spent learning a new skill or disease process. Nary single minute is spent standing around waiting for a case to start or on hold with an outside hospital waiting to request patient records. Indeed, this is the perfect residency that doesn't exist.

But the general rule of thumb is you want to see enough patients, cases, and types of ailments that you will be sufficiently trained to practice independently when you're done with residency--while at the same time not being so scrambled that you don't have time to learn anything, you can't even gather a moment to study for your in-training exams or boards, and you risk your physical or mental health due to lack of personal time and stress. Busy programs that see a large and diverse group of sick patients have the potential to fulfill these goals--but if there are not enough residents, ancillary staff numbers are low, or organization is poor, you risk suffering the downsides of a busy program.

On the flip side, a program that is very light on patients or lacks diversity of patient types and surgical cases leaves you with the risk that you will happily plow through your residency program--free of stress and well prepared for all your written exams--but without having seen large portions of cases and diseases that you will be expected to understand upon completing your training.

Personally, I would recommend seeking residency programs that are large, diverse, and busy--but which do not have obvious reputations of abusing residents, violating work-hour restrictions, or otherwise leaving you no time to process anything you're learning or prepare for your boards and various ACGME-required projects. I would be wary of programs that have reputations of entirely lifestyle-driven and that do not seem to expose residents to the full range of procedures and/or diseases. Obviously, the reality is that most programs are going to lean to one side or the other, and finding the perfect balance can be difficult.

Good luck!

 

[Dires]

Part of this answers your question, but I also tried to generally answer what I felt your bigger question was: "How do I use case volume to assess program quality, and what other program characteristics did you find helpful when ranking programs?"

Low volume is a problem if there are too many residents. A place can have a low volume, but if it is a small program (2 residents per class) and very receptive attendings it may be a great place to train.

High volume is good, but it can also be problematic. Make sure you are given good didactics and that the residents feel like they have time (which is usually not a lot) to study/learn the material correctly the first time.

I think a more appropriate question to ask is about Resident autonomy. What is the programs culture with regards to graduated resident autonomy. This is a bigger indicator on what your operative experience will look like.

Resident didactics are another big topic often overlooked. Ask residents how much time their attendings spend with them going over the decision making process preop, op, and postop. You can learn a lot of it from a book, but in residency a lot of the pearls come from reading the literature and seeing how your attendings apply said knowledge to their practice.

You will get a lot of different opinions on this topic. So read them all and make your own preliminary opinion. Last, the whole process yields a lot of information. Externships especially. So fret not... it will all become clear.