Progression of surgical training

[Treg]

As a student I have been given the opportunity to scrub for a lot of cases, and I am always amazed at the skill/confidence level difference between 1st/2nd year residents and the chief residents/fellows. Can someone outline how the training changes over time? Are the first two years spent mostly watching and helping open/close the incision? When do people do their first open/lap chole? Their first anastemosis? I am just starting out but I am intrigued at the process of becoming a skilled surgeon. Thanks Treg

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[Winged Scapula]

As a student I have been given the opportunity to scrub for a lot of cases, and I am always amazed at the skill/confidence level difference between 1st/2nd year residents and the chief residents/fellows. Can someone outline how the training changes over time? Are the first two years spent mostly watching and helping open/close the incision? When do people do their first open/lap chole? Their first anastemosis? I am just starting out but I am intrigued at the process of becoming a skilled surgeon. Thanks Treg

It depends on the program and "luck of the draw". Conventional wisdom has it that at academic programs you spend most of your 1st and 2nd year learning pre and post op management of surgical patients, with less OR time but that in community programs you spend more time in the OR and less in the ICU and on the wards. However, this is a stereotype and varies between programs, not university vs community.

Secondly, it also depends on being in the right place at the right time with the right attending. Some cases lend themselves better to having an intern actually doing some of the case - sometimes its a matter of the technical skills owned by the resident, sometimes its "how much time do I have to let the resident struggle?", and obviously the interest of the attending in teaching and allowing you the autonomy to do more. I have colleagues who never did a Lap chole until their 2nd year, others who did numerous appys as an intern and others who didn't do any their first year (ie, the local community program gets way more appys than we do, so we don't do them all that often here; I had a friend here locally that did 3 or 4 dozen his intern year. I didn't do a single one until my 2nd year. The first resident mentioned simply wasn't in the right place at the right time to do a Lap chole his first year).

Surgical training is a lifelong process after the completion of a 5+ year residency program. Residency is designed to be graduated responsibility. There is no timeline when "most" residents do their first lap chole (open choles are increasingly rare) or a bowel anastomosis, but the basic surgical skills are obtained during the early years of residency, with the later years designed for honing those and learning more difficult procedures as well as responsibility in managing pre and post op patients, teaching students and more junior residents. There will be a fair amount of variability in skill level between residents at each level and between levels. Some are more gifted technically, others have worked harder (or less hard) and others have simply had more opportunity to increase those skills.

Once one graduates from a residency program, those skills will continue to be honed and even changed as new techniques come to the forefront or the practitioner learns a smarter, better way to operate.

Hope this helps.

 

[matthewtam2002]

Dear Kimberli

I have a few questions regarding operative experience of residents

I often see people saying 'yeah i did 150 cases in my intern year'
or 'i did 2000 cases in my residency'
are these figures valid - i thought the average caseload for a US
resident was about 1200.
also, how do you guys count 'doing the case'?
Is it doing the majority, or a bit, or are these even just scrub counts?

I did a rotation at Johns Hopkins and saw a junior resident, senior
resident and fellow all competing to do bits of the case, would
they then all log it as 'their' case?

Is it also true that an attending has to be present for every single
case?

cheers

 

[Pilot Doc]

I often see people saying 'yeah i did 150 cases in my intern year' or 'i did 2000 cases in my residency' are these figures valid - i thought the average caseload for a US resident was about 1200.

1200 sounds like a credible average, but it varies widely depending on a program's case volume, philosophy and case mix. At a busy program where junior residents operate and can do 3-6 small cases a day, 2000 cases is not at all impossible. ( Residency is about 1500 working days.)

also, how do you guys count 'doing the case'?

Only one person can count a case and must perform over 50% of it. This is obviously open to interpretation. Also, a senior resident may count a case if he takes a junior resident through it.

I saw a junior resident, senior resident and fellow all competing to do bits of the case, would they then all log it as 'their' case?

No, as above, a maximum of 1 (sometimes 2) resident can log a case.

Is it also true that an attending has to be present for every single case?

Strictly speaking, no. For billing and liability insurance reasons, attendings are scrubbed and present for a larger and larger number of cases.

 

[navysurgeon]

you have to log a certain number of chief or TA cases for your op-log...where you take a junior resident through a case. endo cases are counted into your op-log, and most of us add this number to total cases (only about 100 endo cases in my residency)...2000 cases is a high number. in my chief year, the busiest chief had 1680 cases (U of W 2002)

 

[dr.evil]

This is a good thread and a subject that we talk a lot about.

When do you count the case? When I was an intern, a fellow intern and I decided we weren't going to count a case until we thought we were doing it entirely and could do it without the staff or chief in the room. After about two months, we realized that was stupid. There was no way I could know all the idiosyncracies and "tricks" of doing the case. We then read that if you do "50%" of the case then it's yours. Well that's just a difficult concept.

One week into residency I placed all the ports for a lap chole, the attending dissected out the duct and artery and shot the cholangiogram, then I finished clipping the duct and artery and took the gb out. That's definitely doing more than 50% of the case but I didn't count it. In hindsight, as an intern, that's probably a "countable" case. I learned skills of port placement, clipping laparoscopically, and taking the gb off the liver bed. Definitely skills you need. I would definitely not count that today (I'm a 3rd year) as dissecting the triangle is the difficult part of the case.

Anyway, a difficult concept. I guess if you do 50% of the case and you're performing or enhancing a skill that you need, then that counts.

I was doing a Whipple a couple of months ago with staff (yippee the chiefs were at ACS!) and I guess he forgot I was a 3rd year. He really went out of his way allowing me to do a lot of the dissection. I really got uncomfortable around the neck of the pancreas/SMV/Portal areas and he had to hold my hand a lot through that. I did all the anastomoses (my choledochojejunostomy leaked BTW, dammit) which was super sweet. So there is a case that I definitely could not have done without the attending, parts I couldn't do without hand-holding, but I counted it.

I agree that it's still fun to operate with the chiefs and see how much better/efficient they are in the O.R. than me (granted, I suck). It's just like anything else, the more you do it the better you are.

I did 256 endoscopies my intern year so that's probably how we get these astronomical numbers near 2000. You need to ask how many "major" cases someone has.

In the end, it really doesn't matter how many but how well you can do a case.

 

[supercut]

As stated before, it varies somwhat from program to program. THere are also several ways to log a case...first assistant, surgeon Jr, surgeon sr, and teaching assistant. Again, you can claim surgeon if you did >50%. You can't be surgeon sr until you are PGY 4. Teaching assistant means you took someone else through the case

I am a PGY 2 at an academic program. My log from my intern year contains 101 cases. THis year I'm at 75 so far (and I just came out of 2 months in the ICU with no OR time at all) Most of them from intern year are small cases, like draining abscesses, and hernias. For many of these, I was able to claim surgeon jr status. However it also contains some pretty cool stuff like installing a hepatic artery infusion pump and kidney transplants. I claimed first assistant stautus on those, cuz I did some stuff (I was allowed to sew renal vein on the couple of kidney transplants I did...thanks to a very cool attending).

This year I've got a bunch of lap appys, and am starting to do lap choles. Plus I"m doing more sewing on bowel.

IF all I do is hold retractors, I don't count the case at all. For laparoscopy, I don't count cases in which my sole role is cameraman.

AS you move up, you spend more time in the OR. Also, each year you move up, more is expected of you and you are allowed to do more. I was actually amazed at how differently attendings treat me and what they allow me to do now that I'm a 2 vs when I was an intern. Some who let me do almost nothing last year are letting me do a great deal this year.