Optimal Number of Cases During Residency

[Flank Pain]

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Currently interviewing...

There seems to be two extremes at most programs:
1. Community: 1300-1400 cases with only 1-2 months dedicated ICU time
2. Academic: 850-1200 with 1-2 to 10-11 months dedicated ICU time

There are obviously variations on this theme, but this is how I have come to look at it: the community programs are training surgeons that can treat a diagnosis (at some programs an impressive range of diagnoses) and refer complex problems to the super-specialist academics; academic programs residents maybe spent more time learning about patient management, and emerge residency capable of taking care of any patient but most go on to fellowship to learn to operate on a few of them. Most academic residents seem to indeed WANT to go onto fellowship, but I get the impression that some of the do really NEED to go onto fellowship.

I think that most of us have that nagging questions though--what if I decide I want to be a general surgeon when I am done training at X big academic program? Is 850-1000 cases enough operative experience? Is that really enough technical experience, this is a very intellectual field no doubt, but at some point knowing what to do is of minimal importance if you don't have the practice to technically perform the case safely and competently. I am aware that the RRC says 750. That 750 is the bare minimmum. Any less that that and you would be dangerous, seems like it would be nice to be at least aways from that line when you are done no matter what you are going to do next.

I am curious what people at more academic programs with the 800-1000 case range think about this--do you think you could walk out the door at the end and compete with a community trained surgeon?

 

[doc05]

this is something you'll figure out once you're in residency. "Case numbers" that a program reports on your interview day can be very misleading; unfortunately there's little you can do now to determine what those numbers mean.

As far as fellowship, 70+ percent of grads go on to fellowship, for a variety of reasons. Even if you become well-trained in your residency and want to be a community-practice general surgeon, a yearlong fellowship in laparoscopy or some other field may be to your benefit. Too bad it's nearly impossible to figure this out now while you're on the interview trail.

 

[Winged Scapula]

Agree with the above.

Case numbers are notoriously manipulated and you have no way of knowing what's real during interviews. In addition, how many cases YOU need (or will get) during residency to be what YOU feel is competent is different than the guy or gal next to you. Factor in the knowledge that there may be no significant difference in doing more of the same once you have reached a level of expertise and that everyone gets better out in practice once they are doing these cases regularly, and you can see that case numbers are not a good measure of quality. Remember the 750 is a recent minimum...it was 500 just a couple of years ago.

Over 70% of current surgery residents seek fellowship, and that's true for community programs as well. Yes, some do NEED fellowship for additional training - either for the skills or to make themselves marketable. That again, is program independent.

You don't really know what you want to be right now. Perhaps you will end up being a community general surgeon, or perhaps a fellowship trained academic position will strike your fancy. I never envisioned myself practicing out in the community and you can say that my nearly a year of ICU training was a waste and that I should have gone to a community program. But things change.

Find the program that best fits you...I can't see a significant difference between 1200 cases and 1300 cases. 850 is pretty low, but as noted above there are many reasons for case numbers being what they are - high and low.

 

[Khirurg]

Number of cases is such a misleading thing. How do you log your cases? Do you log every case that you scrub on? Or the case where you did at least half? Does that mean that you actually did the case? And if you did the case, does it mean that if next time left alone in the room with a junior who doesn't know what to do, you can do it yourself?
750 cases where you DID at least half of the case is plenty. How many right colons do you need to learn how to do a right colon? Or gallbladders? Or thyroids? Bottom line is, you should make sure that graduating residents do not have deficiencies in the defined categories. Meaning, chiefs are not lacking pancreas cases or liver cases. As far as numbers are concerned - some people cannot learn how to operate after 1000 cases, for some 500 is enough. Community vs academics is overrated. It is up to you - your skills, your talent and your work ethic.

 

[SLUser11]

Number of cases is such a misleading thing. How do you log your cases? Do you log every case that you scrub on? Or the case where you did at least half? Does that mean that you actually did the case? And if you did the case, does it mean that if next time left alone in the room with a junior who doesn't know what to do, you can do it yourself?
750 cases where you DID at least half of the case is plenty. How many right colons do you need to learn how to do a right colon? Or gallbladders? Or thyroids? Bottom line is, you should make sure that graduating residents do not have deficiencies in the defined categories. Meaning, chiefs are not lacking pancreas cases or liver cases. As far as numbers are concerned - some people cannot learn how to operate after 1000 cases, for some 500 is enough. Community vs academics is overrated. It is up to you - your skills, your talent and your work ethic.

People keep mentioning that case numbers can be misleading, and it depends on what the resident is logging as "surgeon junior," however nobody has mentioned that the same places that struggle for numbers are the most likely to fudge their numbers and count things that they probably shouldn't.

In my opinion, I would be the most nervous about places with low numbers, as those residents have the most motivation to artificially elevate their case logs. In a program where people are logging 1300 cases as surgeon junior and surgeon chief, they really don't have as much reason to lie about their participation in a case, because they've got plenty of cases.

Since the definition of "doing a case" can be somewhat unclear, it's probably best to look at the numbers across the board, and make sure that all of the graduating chiefs have similar numbers without any significant outliers. That may help identify some number fudging....unless they're all liars, of course.

Through November of my PGY-4 year, I've logged 754 total major cases (with relatively strict definitions of doing the case). However, I've logged 1664 cases overall....everything from first assist to TA to all those things that don't count (nephrectomies/transplants to gyn cases to portacaths to CVLs and tubes). I've had over 6 months of dedicated ICU time where I manage the entire unit, plus frequent ICU care throughout my other rotations.

I come from a solid university-affiliated community program, but my experience is not unique, and my operative numbers are not overly-impressive. There are plenty of places that offer a balance of operative experience, ICU care, academics, multi-system patient management, and manageable lifestyle. You just have to look for them.

My advice: Don't go anywhere that has an obvious deficiency in ANY of the categories mentioned above. If you get 1500 cases but can't manage a sick patient, then your education was inadequate. If you can quote studies left and right, and know lots of big names, but it takes you 4 hours to do a gallbladder, then your training was inadequate.

Find a place with balance, become a solid board-certified general surgeon, then decide if you want a fellowship based on your interests.

 

[gerickson03m]

I remember reading an article last year... the average number of major cases from graduating residents were 940-950, and the curve was quite steep so that if u were graduating with 1000 cases, you were in the 70th percentile. The number of total cases is a complete bull**** number as some losers count central lines and such.

 

[Celiac Plexus]

The only reason that a resident should log cases, is to document the minimum number of cases required to sit for the boards. As it stands now, the number is 750.

There is no prize for logging the most cases. The ABS does not care if you did 750 cases (and met all of the defined categories), or 1500.

The case log is NOT a measure of surgical ability. I.e., a pgy-5 with 1200 cases logged is not a better operator than a pgy-5 with 750 cases logged.

Your program will likely pressure you to log as much as possible so that on interview day, the PD can point to the pgy-5s having an average of 1500 cases. This is so that, as an applicant, you will think "Gee, this place gives residents great operative experience", and you will rank them highly.

Let me be one of the many voices here who will tell you that logged case numbers mean very little. They certainly speak nothing as to the quality of surgical training, or the quality of the resident operative experience. The case logs are only used by programs as recruiting tools.

As an example, I graduated general surgery with 3-400 cases less than a friend of mine at a different general surgery program. I spent my chief year TAing fem-pops, colons, nissens, thyroids, appies, GBs, and running every service I was on. He spent his chief year never doing a single case by himself, never TAing a single case, and could not make a skin incision without the attending scrubbed in and standing across the table from him. His numbers were significantly higher than mine. My "operative experience"... significantly better than his.

So, if I were you, I would ignore case numbers when you go to interviews. Talk to the residents (privately if you can), and follow your gut instinct. Try to train at a place that does not have a lot of fellowships if possible. Much of your surgical education will depend on you. If you work hard, read a lot, do well academically, manage your patients well, and show up to your cases having read about them, you are much more likely to be given autonomy in the OR. If you are one of those folks who just shows up and needs to be spoon-fed, you will probably not be given much autonomy.

Take home message: logged numbers mean nothing when it comes to the quality of the operative experience, and quality of operative teaching. Just make sure the program is consistently getting the minimum numbers so that all of their chiefs can sit for the boards.

 

[SLUser11]

The number of total cases is a complete bull**** number as some losers count central lines and such.

I included my total # cases to illustrate that I wasn't padding numbers by counting everything as a surgeon junior. "Counting" central lines or not, I think the real loser is the person who had an inadequate operative experience and has to then justify it somehow. I enter most cases that I perform (that is, when I remember to get a sticker). It's not because I'm trying to reach some special high number...it's because that's what the ACGME wants us to do, and I'm not sure how it's going to factor in to hospital privileges down the line.

Explain to me why logging my CVLs and minor cases makes me a loser. I'm curious to know.

The only reason that a resident should log cases, is to document the minimum number of cases required to sit for the boards. As it stands now, the number is 750.....
There is no prize for logging the most cases. The ABS does not care if you did 750 cases (and met all of the defined categories), or 1500.

The ACGME cares. Unless all of your co-residents have a near-identical "who cares" approach to logging cases, you'll be dinged for having too much variation in numbers.

The case log is NOT a measure of surgical ability. I.e., a pgy-5 with 1200 cases logged is not a better operator than a pgy-5 with 750 cases logged.

Depends on how you look at it. A Chief who has done 200 colectomies could very well be better at them than the chief who has done 50 colectomies.

Let me be one of the many voices here who will tell you that logged case numbers mean very little. They certainly speak nothing as to the quality of surgical training, or the quality of the resident operative experience. The case logs are only used by programs as recruiting tools.

This is simply not true. While there are some exceptions, low volume will result in low case logs. On the other hand, I doubt that high volume results in low case logs as often.

So, if I were you, I would ignore case numbers when you go to interviews. Talk to the residents (privately if you can), and follow your gut instinct.

Please don't ignore those numbers. If you see residents graduating with 751 cases, don't assume they really have thousands of cases, but they're just too cool to log them. Assume there is a deficiency in their numbers.

I do agree, however, with talking to the residents and following your gut. Remember that a lot of the residents are full of crap, though, and they're trying to sell you somethings as well. I doubt you'll find many places, regardless of volume, where the residents will admit that they have problems with numbers.....does that mean such places don't exist?

Take home message: logged numbers mean nothing when it comes to the quality of the operative experience, and quality of operative teaching. Just make sure the program is consistently getting the minimum numbers so that all of their chiefs can sit for the boards.

This is just ridiculous. There is obviously a correlation between case logs and overall operative volume. As for the quality of the operative experience:

Types of cases: Those numbers are available.
# of TA cases: Those numbers are available.

The only thing you don't know is how much autonomy the resident gets inside the operating room. I think the # TA cases can help with that, but this is the situation where talking to the residents is the most important step.

I won't name names, but as a student, I encountered 3 separate programs with inadequate operative experiences. Two of them were university programs with very low volume, and chiefs with the inability to safely perform simple procedures due to lack of experience. I interviewed at both, and they had case logs in the 800 range. The other program was a straight community program with lack of autonomy, and chiefs who were still assisting to some degree. Their case logs were in the 1000 range. Three very different places, same outcome.

I understand where these other current and past residents are coming from, but I think their advice can hurt current applicants, because they are asking you to ignore a deficiency, which is never a good idea.

That's like telling an applicant not to worry that lots of residents have left a program, because they probably weren't cut out for surgery, or to ignore that a program is on probation, etc.

 

[Khirurg]

Explain to me why logging my CVLs and minor cases makes me a loser. I'm curious to know.
nobody is calling anyone a loser here. but what is a reason to log every central line? or chest tube?

Depends on how you look at it. A Chief who has done 200 colectomies could very well be better at them than the chief who has done 50 colectomies.
yes, but not necessarily. Did the chief take a second year through the case, dissecting everything himself, or was the chief bovieing while atteinding was dissecting. Huge difference. You can learn a lot by watching, but you have to make transition at some point. 50 independent colectomies are far more valueable that latter 200 scenarios.

This is simply not true. While there are some exceptions, low volume will result in low case logs. On the other hand, I doubt that high volume results in low case logs as often.
Possibly. But look at it this way. In NY where i am from, there is a place called Memorial Sloan Kettering. Many places send their residents there. The residents scrub with fellows and technically can log every case the scrub. How much of the case they really do? From talking with some of them (people from different programs, ours doesn't send residents there) - not much. But in the end you get 200 colectomies. Are you a better surgeon because of that? Sure. But does that count as 200 colons you did? I woudn't say that.


Please don't ignore those numbers. If you see residents graduating with 751 cases, don't assume they really have thousands of cases, but they're just too cool to log them. Assume there is a deficiency in their numbers.

I do agree, however, with talking to the residents and following your gut. Remember that a lot of the residents are full of crap, though, and they're trying to sell you somethings as well. I doubt you'll find many places, regardless of volume, where the residents will admit that they have problems with numbers.....does that mean such places don't exist?




This is just ridiculous. There is obviously a correlation between case logs and overall operative volume. As for the quality of the operative experience:

Types of cases: Those numbers are available.
# of TA cases: Those numbers are available.

The only thing you don't know is how much autonomy the resident gets inside the operating room. I think the # TA cases can help with that, but this is the situation where talking to the residents is the most important step.

TA cases is another thing. You presumed to log a case where you took a junior through, but was is that two of scrubbed the case and one was bovieing and another retracted? How would you know?

All the points are well taken. Bottom line is - you cannot trust the numbers. They don't tell the whole story, and can totally mislead you My personal view - rotate through the place and see for yourself.

 

[SLUser11]

nobody is calling anyone a loser here. but what is a reason to log every central line? or chest tube?

yes, but not necessarily. Did the chief take a second year through the case, dissecting everything himself, or was the chief bovieing while atteinding was dissecting. Huge difference. You can learn a lot by watching, but you have to make transition at some point. 50 independent colectomies are far more valueable that latter 200 scenarios.

Possibly. But look at it this way. In NY where i am from, there is a place called Memorial Sloan Kettering. Many places send their residents there. The residents scrub with fellows and technically can log every case the scrub. How much of the case they really do? From talking with some of them (people from different programs, ours doesn't send residents there) - not much. But in the end you get 200 colectomies. Are you a better surgeon because of that? Sure. But does that count as 200 colons you did? I woudn't say that.

TA cases is another thing. You presumed to log a case where you took a junior through, but was is that two of scrubbed the case and one was bovieing and another retracted? How would you know?

All the points are well taken. Bottom line is - you cannot trust the numbers. They don't tell the whole story, and can totally mislead you My personal view - rotate through the place and see for yourself.

Who in the world would count a case as a TA if they are first assisting the attending? If this is the practice that you guys have experienced, then I can see why you are skeptical of numbers.

Still, I feel like you guys are basically calling all general surgery residents liars. Where I'm from, they don't count cases that they don't do. End of story. If you scrub a case, and you were boveing between the staff's right angle, then you were the first assistant, and should log the case as such.


Is that different where you guys trained? If so, what region of the country did you train in, and in what type of program? Maybe this will help the applicants know what type of programs produce this deception.

As for the "loser" comment, it wasn't you. Still I log them for the reason mentioned above: I want all such procedures documented in case it affects my credentialing at different hospitals. The same goes for endoscopy. We get well above the required # for graduation, but I keep track of all of them for future privileges. Do I log all of them? No, I often forget. But, if a sticker ended up in my pocket, then it gets put in the computer....and I don't see the harm or the nerdiness in that.




Oh I forgot another good idea for determining resident autonomy: Talk to the interviewing students who are from that program.....they have less to gain from deception, and have more first-hand knowledge of the OR dynamic.

 

[Celiac Plexus]

The ACGME cares. Unless all of your co-residents have a near-identical "who cares" approach to logging cases, you'll be dinged for having too much variation in numbers.

This is true. But again, this has nothing to do with quality of surgical education. And I am not advocating a "who cares" approach to logging cases. I recommend logging your cases accurately, honestly, and in a timely manner.

Depends on how you look at it. A Chief who has done 200 colectomies could very well be better at them than the chief who has done 50 colectomies.

This is possibly true as well. I don't think that I suggested otherwise. The point of my post is that case logs are not a measure of quality of surgical education. One cannot draw any meaningful conclusions about the educational experience of a program based on case logs alone. Consider that a chief with 200 colons logged could actually be worse than a chief with 50 logged.

While there are some exceptions, low volume will result in low case logs. On the other hand, I doubt that high volume results in low case logs as often.

I disagree. Many residents I knew in residency were not good about logging their cases (myself included). One of the best residents (technically speaking) was terrible about logging his cases. And some of the most anal loggers were pretty average technically.

Additionally, I knew residents in other programs that engaged in sketchy logging practices to meet their case minimums, or just to inflate their numbers. Is this a common practice? I don't know. But again, it speaks for the notion that case logs are not reliable indicators of operative experience, or quality of surgical education. Case logs rely on the individual resident to accurately, and honestly report their experiences. You can imagine the inherent potential for "inaccuracies".

Please don't ignore those numbers. If you see residents graduating with 751 cases, don't assume they really have thousands of cases, but they're just too cool to log them. Assume there is a deficiency in their numbers.

Actually, don't assume anything about case logs. I don't think anyone here is suggesting that residents who have logged 751 cases "really have thousands of cases". There's really no good way, from an applicant standpoint, to know anything about case volume except that the residents log enough cases to sit for the boards.

This is just ridiculous. There is obviously a correlation between case logs and overall operative volume.

I'll take your word for it. However, to repeat, case logs don't reveal anything about the quality of a surgical education. Program A may have higher operative volume than Program B, but if the residents at Program A have no autonomy, and are glorified Bovie kings, than Program B probably is the better surgical experience.

I understand where these other current and past residents are coming from, but I think their advice can hurt current applicants, because they are asking you to ignore a deficiency, which is never a good idea.

That's like telling an applicant not to worry that lots of residents have left a program, because they probably weren't cut out for surgery, or to ignore that a program is on probation, etc.

I don't think anyone here is suggesting that applicants ignore deficiencies in a program. I'm simply making the case that case logs do not have anything to do with the quality of a surgical education.

I would never, and I don't think that other posters are suggesting this either, recommend to an applicant to overlook the fact that a program is on probation. Or that applicants should ingnore a program's high attrition/firing rate. These are important pieces of information.

There are just so many variables with logging cases, that to use case log numbers as major indicators of quality of surgical education is not a good idea. In fact, the match process is somewhat of a crap shoot. Definitely pay attention to everything at your interview, and don't ignore anything per se. However, take case log numbers with an enormous grain of salt.

Good luck to this year's applicants.

 

[LucidSplash]

The only reason that a resident should log cases, is to document the minimum number of cases required to sit for the boards. As it stands now, the number is 750.

There is no prize for logging the most cases. The ABS does not care if you did 750 cases (and met all of the defined categories), or 1500.

Though not strictly for the resident's sake, it seems that an additional reason to log cases properly, past the 750 minimum, is that programs that are applying for an increase in spots need to show an excess of volume beyond the minimum covered by current residents. I have interviewed at at least one program that was denied a permanent increase, after having received a temporary increase at the prior site visit, because residents had not been logging all their cases in certain areas beyond the minimums. So, despite actually having the volume, the couldn't prove it.

 

[SLUser11]

This is true. But again, this has nothing to do with quality of surgical education.

This is possibly true as well. I don't think that I suggested otherwise. The point of my post is that case logs are not a measure of quality of surgical education.

But again, it speaks for the notion that case logs are not reliable indicators of operative experience, or quality of surgical education.

I'll take your word for it. However, to repeat, case logs don't reveal anything about the quality of a surgical education.

I don't think anyone here is suggesting that applicants ignore deficiencies in a program. I'm simply making the case that case logs do not have anything to do with the quality of a surgical education.


There are just so many variables with logging cases, that to use case log numbers as major indicators of quality of surgical education is not a good idea. In fact, the match process is somewhat of a crap shoot. Definitely pay attention to everything at your interview, and don't ignore anything per se. However, take case log numbers with an enormous grain of salt.

Good luck to this year's applicants.

You just said the same thing like 40 times, without making any new points. As I said, there should be multiple factors that go in to choosing a program. Operative volume is just one of them. The quality of the surgical curriculum/education is another extremely important variable.

You're right that big numbers don't guarantee that you'll get a good education. However, low numbers could very well mean that you don't see the inside of the operating room as much as you'd like.....and it can't be ignored. End of story.

Take it with a grain of salt? Sure, because big numbers mean different things in different places. But ignore it completely? Not a good idea.


I also disagree when you say that the match is a crap shoot. It can be if you don't put the work in. But if you do the research and go into the process well-informed, but it doesn't have to be. As for the quality vs. quantity debate, it's probably best if you can have both. However, make the wrong decisions during the match, and you could end up with neither one.

 

[Celiac Plexus]

You just said the same thing like 40 times, without making any new points. As I said, there should be multiple factors that go in to choosing a program. Operative volume is just one of them. The quality of the surgical curriculum/education is another extremely important variable.

The OP's original question:

"I am curious what people at more academic programs with the 800-1000 case range think about this--do you think you could walk out the door at the end and compete with a community trained surgeon?"

My responses to this question revolve around the notion that case log numbers should not be the determining factor of whether a program provides an excellent surgical education. As you say, "end of story".

You're right that big numbers don't guarantee that you'll get a good education. However, low numbers could very well mean that you don't see the inside of the operating room as much as you'd like.....and it can't be ignored. End of story.

That is my point. Big numbers don't guarantee anything. And I'll take it a little further by saying that lower numbers don't necessarily mean you will get a suboptimal experience.

Take it with a grain of salt? Sure, because big numbers mean different things in different places. But ignore it completely? Not a good idea.

I don't think I ever suggested applicants should ignore case log numbers completely.

I also disagree when you say that the match is a crap shoot. It can be if you don't put the work in. But if you do the research and go into the process well-informed, but it doesn't have to be. As for the quality vs. quantity debate, it's probably best if you can have both. However, make the wrong decisions during the match, and you could end up with neither one.

Well, we will have to agree to disagree. Applicants can never really know everything about a program, and programs are constantly in flux. The program I matched into out of medical school was a completely different program I graduated from because of numerous personnel changes, and hospital/medical school policy changes, etc. Over the span of a 5-7 year residency, things can change a whole lot.

Very decent of you to note that I repeated myself "like 40 times". I guess I like repetition, and you like bolding every other word.

Best of luck in the rest of your training.

 

[SLUser11]

Well, we will have to agree to disagree.

Agreed. I think we have two different perspectives that just won't meet.

As for the bolding, I find it annoying, too, but it's just so hard to add emphasis and inflection in another way. Without it, all my preachy sentences just run together.

Still, a 3rd party observer might see your need to change residencies as an indicator that your "crapshoot" approach didn't work out. I'm sure there's more to the story regarding your change, but I still find it a little ironic, given your earlier comments.


Anyway, I'll settle down for a little while. I was stuck in the hospital through the holidays, and I think I was getting a little belligerant.....just ask the CC forum....

 

[Flank Pain]

There were some great responses here, and they were helpful. I now believe that the case numbers mean nothing, and this coupled with the unabashed propaganda delivered by residents and program directors at every interview ("This is a top surgical training program", "Our residents operate early" vs. "Our chief operate non-stop", and the oh so ubiquitous "We are training the future leaders of surgery", "We all get along great" and my personal favorite "This program way my first choice because...). has convinced me that there is actually no meaningful way to evaluate the quality of any surgical training program. And besides, any deficiences have been corrected, our board pass rate for the past (insert time frame here) have been great, we never break the work hours restrictions, rent isn't that bad, our seniors get their top fellowship choices, you could go into community practice despite the fact that (insert high percentage number here) end up in academics (what exactly "academic" is remains hazily illdefined), parking is cheap, the meal cards never run out of money, and the ancillary staff is great. We also have a new wing with (insert number of "state of the art ORs here) that will be finished by the time you arrive, and the piece de la resistance...we have plasma screen TVs in the call rooms, and beer on tap from 99 foreign countries in addition to the selections form our local breweries that serve as one more example or our locations cultural high-browness. YOU ARE GOING TO LOVE IT HERE, tell your friends.

I have now decided to try and match somewhere with the nicest weather, highest salary, least intern call and most weeks of vacation, because hey, why not. California, baby, here I come.

 

[SLUser11]

There were some great responses here, and they were helpful. I now believe that the case numbers mean nothing, and this coupled with the unabashed propaganda delivered by residents and program directors at every interview ("This is a top surgical training program", "Our residents operate early" vs. "Our chief operate non-stop", and the oh so ubiquitous "We are training the future leaders of surgery", "We all get along great" and my personal favorite "This program way my first choice because...). has convinced me that there is actually no meaningful way to evaluate the quality of any surgical training program. And besides, any deficiences have been corrected, our board pass rate for the past (insert time frame here) have been great, we never break the work hours restrictions, rent isn't that bad, our seniors get their top fellowship choices, you could go into community practice despite the fact that (insert high percentage number here) end up in academics (what exactly "academic" is remains hazily illdefined), parking is cheap, the meal cards never run out of money, and the ancillary staff is great. We also have a new wing with (insert number of "state of the art ORs here) that will be finished by the time you arrive, and the piece de la resistance...we have plasma screen TVs in the call rooms.

I have now decided to try and match somewhere with the nicest weather, highest salary, least intern call and most weeks of vacation, because hey, why not. California, baby, here I come.

You are right. As some of the other posters here have pointed out, some surgery residents are prone to lying....especially when trying to convince you to join their world of pain. Most of them want to train with good people, and they also want you to think that 1) They got their #1 choice, and 2) they made the right decision.......

My advice: Develop a good bulls#@t meter.....being able to tell who's lying through their teeth and who's being honest will take you far. Also, as stated before, talk to the students from that program. They will give you the dirt....sometimes...othertimes they're serving the same kool-aid as the residents.

Also remember that if they can't turn it off for one night, meaning that they can't help but complain or b@#ch or talk crap about a resident or attending at the pre-interview social, then it's probably pretty miserable there.

 

[Celiac Plexus]

Still, a 3rd party observer might see your need to change residencies as an indicator that your "crapshoot" approach didn't work out. I'm sure there's more to the story regarding your change, but I still find it a little ironic, given your earlier comments.

To clarify: I did not change residencies, or programs. I started, and completed, residency at the same program.

What I meant by my previous post was that the residency program changed tremendously while I was training in it. There was faculty turnover, administrative changes, hospital policy changes etc... so that by the end of my training, my residency was a very different one from the one I started.

 

[JayDoc06]

1) Don't kid yourself, of course case numbers matter. Every case is different and no matter what anyone says, you can never see enough unless you're talking about abscesses or doing your 100th hernia prevents you from doing something else instead.

2) The case numbers shown while interviewing reflect the overall volume of the program. The one thing you cannot supplement during residency, no matter how brilliant, hard-working, or beautiful you are, is volume. I doubt very much that anyone would just sit down and create cases out of thin air.

3) DO pay attention to diversity of case types. Though it all translates into a total number of major cases, the specific breakdown is important. You need to find a program where you will see it all, and that information is discoverable by you the paranoid applicant.

4) I log every single thing I do, including minors, lines, abscesses, first assists, TAs, everything. I do this for 2 reasons:

- First, nobody is going to give you a dime in practice unless you have hard evidence that you did it. The same way you "practice" gallbladders, you should practice the things that will help you become a financially successful surgeon (including small things like dictating and documenting properly...)

-Second, when it comes to getting privileges, you need to be able to show that you have done enough APR's in residency to do them in practice. Hospitals do not care if you were TA, Surgeon Jr or even First Assistant. Log your cases.

5) Remember, every program you go to is advertising- highlighting the strengths and minimizing/ignoring/lying about the deficiencies. Some much more than others.

Pick a place based on your anticipated career goals keeping in mind that a majority of residents change their minds. So, find a place where your options will be open and your fate is not sealed on Match Day. You must like the people you work with and NOT HATE the city you will live in for 5+ years. The era of the inadequate training program is over- all programs offer a minimum level of training that produces an acceptable product.

Happy match-listing!

 

[jc7721]

Lots of salient points in the above posts.

Total operative experience, including total major cases, is not at all reflective of the breadth of operative experience. I agree that if chiefs are all graduating with 751 major cases, there is probably reason for concern, but on the flip side, if chiefs have 1600 major cases, the same applies.

What is the breakdown of those 1600 or 751 cases? It is not a secret that community programs typically operate A LOT more than academic programs (though there are exceptions), but it is also not a secret that the case mix is usually different. These things will never change.

I know friends at community and military training programs that have done 150 inguinal hernias, 150 choles and 50 colons through the first 3 years. If they graduate with, say 1400 major cases, likely >25% will be from hernias, GBs, and colons. That could be a great thing for them, especially if they want to be a community general surgeon. And of course they'll do some of everything else. My mix at a university program is probably quite different. Only 15% of my cases will come from those 3 operations, and I will have about 1000 major cases in the end. 125-150 will be major vascular (mostly bypass/carotids/aorta/fistula), 100 complex lap (primarily nissen/hellers/ing hernias/colons/gastric bypasses), 150 trauma op, 50 liver/panc, 50 endo (thy, para, adrenal), 75-100 breast, 50 colorectal, 50 thoracic (non-trauma), 50 GBs, 50 inguinal hernias, 25 peds, 25 plastics, and the last 150-200 cases will be a mix of all the other stuff. I bet that my defined category 'abdomen' and 'basic lap' numbers will be significantly lower than my community collegues, but I will have significantly more numbers in other categories.

Most places will NOT have chiefs that have 751 or 1600 cases, it'll be somewhere in the middle. Ignore what the total number is, and instead try and get a breakdown of the types of cases they are doing. Most residents will gladly tell you how many cases of a particular sort they've done.

You might even be surprised at what you find. Each program is different. Also, you will unfortunately never be able to determine in one interview weekend what the level of autonomy is. Try your best to get as much information as possible from residents and current medical students about this, but in the end you'll have to go with your gut instinct whether you truly believe what you're being told.

 

[Darksmurf]

This is not totally related to this thread, but has anyone read Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg. 2009 May;249(5):719-24. doi: 10.1097/SLA.0b013e3181a38e59 ?

They make reference to this list of 121 procedures that program directors think GS residents should be proficient at by the end of residency, but they do not provide the whole list. I've tried to find out where to get the whole list but have been unsuccessful.

Anyone know where I can get a copy of the list?

Thanks.

 

[balaguru]

Email the lead author.

 

[SLUser11]

This is not totally related to this thread, but has anyone read Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg. 2009 May;249(5):719-24. doi: 10.1097/SLA.0b013e3181a38e59 ?

They make reference to this list of 121 procedures that program directors think GS residents should be proficient at by the end of residency, but they do not provide the whole list. I've tried to find out where to get the whole list but have been unsuccessful.

Anyone know where I can get a copy of the list?

Thanks.

Oh, man...I really used to love to argue!

I am much more calm and collected now.

Of course, 4 years later I stick by my original comments. Volume is important, and places without adequate volume will have a wonderful "quality over quantity" excuse to feed the applicants.

Applicants should also refrain from assuming that there is some universal distinction between community and academic programs in regards to volume and variety of cases, or time in the ICU. I've now been a student, resident, fellow, and attending in several different academic and community environments, and there is significant variability that goes way beyond community/academic divide.

Like a wise resident once said 4 years ago, it's best to find a program with a balance of experience....bolded text for old-time's sake.

 

[filter07]

Maybe my program is awful but aside from my chief year I don't think there were very many cases where I did more than 50% of a case. What does that mean really. If the attending guides you between the right angles to mobilize the white line, tells you where to create the mesenteric defect, but you fire all the staples after things are all demarcated, is that 50%?

 

[SLUser11]

If the attending guides you between the right angles to mobilize the white line, tells you where to create the mesenteric defect, but you fire all the staples after things are all demarcated, is that 50%?

You picked a difficult case. Open colectomies are usually a two-man job. If the attending directed the course of the case, but you were the one physically performing all the steps, then you should count it as surgeon junior.

Burning between the attending's right angle is not doing the case, so I've avoided counting those cases in the past, whether it was an AV fistula, inguinal hernia, or other similar thing.

I've always tried to focus less on the 50% concept and more on the critical portions concept.

For gallbladders, I would count it if I dissected out the duct and artery, but not if I just burned the gallbag off the liver bed (which I occasionally did as an intern). For hernias, I counted it if I dissected out the hernia sac, but not if I just helped sew in the mesh. For carotids, I counted it if I dissected out the artery and performed the endarterectomy, but not if I just sewed on the patch.

Here's another thread about case numbers. As you can see, I performed a lot of cases that didn't count toward the final number....whether it was because they were first assist, or because it wasn't a defined major case.

 

[Miami_med]

SLUser seems to have had an excellent residency experience. He certainly did things that I haven't done coming to the end of my chief year. That being said, I think most of us have an experience somewhere between what he describes and the "bovies between right angle." experience. I have attendings that don't scrub and let me take the junior through a case. I have others that stay while I close skin. Some right angle me, some don't.

If I scrub a whipple, do part of the dissection, sew the hepatico-J and Gastro-J, but the attending sews the pancreatico-J, should I not log that?

I feel very well trained and feel that I could walk out into practice. I've logged 950 cases in early October of my chief year. I'll likely finish with close to 1200. I'm at a community program.

 

[dpmd]

Maybe my program is awful but aside from my chief year I don't think there were very many cases where I did more than 50% of a case. What does that mean really. If the attending guides you between the right angles to mobilize the white line, tells you where to create the mesenteric defect, but you fire all the staples after things are all demarcated, is that 50%?

I let students fire the staplers sometimes. I wouldn't consider that alone enough to say you did the case, but if you were the only resident there and you tried to do stuff like identify the correct area to divide in order to do an appropriate resection, or line things up so the stapler is doing the right stuff for however you are using it I think calling yourself surgeon junior is fine (some attendings are less patient than others, but if you were prepared to do the dissection and some decisions I don't think you should be penalize-if you walked in with no clue how to do it and just let them walk you through everything then maybe a first assist might be more appropriate, particularly as a more senior resident).

 

[dpmd]

SLUser seems to have had an excellent residency experience. He certainly did things that I haven't done coming to the end of my chief year. That being said, I think most of us have an experience somewhere between what he describes and the "bovies between right angle." experience. I have attendings that don't scrub and let me take the junior through a case. I have others that stay while I close skin. Some right angle me, some don't.

If I scrub a whipple, do part of the dissection, sew the hepatico-J and Gastro-J, but the attending sews the pancreatico-J, should I not log that?

I feel very well trained and feel that I could walk out into practice. I've logged 950 cases in early October of my chief year. I'll likely finish with close to 1200. I'm at a community program.

I don't think it matters much whether or not you log that whipple as long as you don't think that just because you logged a bunch like that, you should go ahead and do that when you start practicing in the community (assuming you don't do a fellowship).

 

[neusu]

this is something you'll figure out once you're in residency. "Case numbers" that a program reports on your interview day can be very misleading; unfortunately there's little you can do now to determine what those numbers mean.

This is a bull**** notion. Clearly, involvement in the case plays a role, but higher case numbers are always better.

 

[Miami_med]

I don't think it matters much whether or not you log that whipple as long as you don't think that just because you logged a bunch like that, you should go ahead and do that when you start practicing in the community (assuming you don't do a fellowship).

Don't worry. It is likely that I won't choose to do Whipples in the community, though it's more a function of desire than not thinking i could safely do them.

 

[surgicel]

great discussion