Question about ACGME case log system

[Orange Julius]

So far I've been logging my cases as "first assistant". I'm talking about the cases where it's just me and the attending doing the case. But I just noticed that none of my cases are counting toward my defined catagories. Apparently only cases logged as "junior surgeon" count. When the case is done with just myself and the attending am I the "junior surgeon"?

The ACGME manual describes the "surgeon junior" catagory as "all cases credited as surgeon prior to chief year. But credited by who? How do I find this out?

Am I "first assistant" only when there's a more senior resident there too?

Also, am I supposed to be logging my hours somewhere also? No one's mentioned that to me. I'm keeping a record of them but I havn't logged them anywhere yet.

Any advice would be appreciated. Thanks.

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[Blade28]

If you're doing more than 50% of the case, I'd log it under "Surgeon Junior."

I'd also keep a log of your daily hours in case your program asks for it.

 

[Celiac Plexus]

There is a tendency to underlog your cases as an intern or 2. If you do not log a case, then it is as if you have not done it. Documentat *everything* you do.

Documenting cases is important when it comes to getting privileges at hospitals you will eventually work in. For example, greenfield filters, percutaneous tracheostomies, central line placement with sonographic/fluoroscopic guidance... these are all basic procedures that are very lucrative. You do not want to be denied privileges to do them just because you didn't document them in residency.

Another tip is to log *everything* you do in a case. Some attendings will code only one CPT code on the op record. It is permissible to log things your attending did not if you actually did them. For example, if you did an ex-lap, and lysed a bunch of adhesions, resected some small bowel, repaired some enterotomies, and took the appendix... the attending may just log the ex-lap, sb rsxn, and appy. You should log these codes, but also log the enterolysis, and enterotomy repairs. This is important because if you are low in a certain category toward the end of your residency, you can go back to the oplog and claim credit for a different CPT code.

 

[njbmd]

So far I've been logging my cases as "first assistant". I'm talking about the cases where it's just me and the attending doing the case. But I just noticed that none of my cases are counting toward my defined catagories. Apparently only cases logged as "junior surgeon" count. When the case is done with just myself and the attending am I the "junior surgeon"?

The ACGME manual describes the "surgeon junior" catagory as "all cases credited as surgeon prior to chief year. But credited by who? How do I find this out?

Am I "first assistant" only when there's a more senior resident there too?

Also, am I supposed to be logging my hours somewhere also? No one's mentioned that to me. I'm keeping a record of them but I havn't logged them anywhere yet.

Any advice would be appreciated. Thanks.

Hi there,
As Blade28 said, if you did more than 50% (at my intitution is more than 75%) of the case, you can start logging as surgeon junior. I made the switch from first assistant to surgeon junior about halfway through my first year with about 150 cases under my belt (but that was back before the 80-hour work week). I also log every central line, every PAC, every arterial line, chest tube, every temporary and permanent pacemaker etc. Anything that I dictate gets logged.

If you do more than 75% of the case, and another more senior resident is there teaching you, then that resident should take TA and you take surgeon junior. (I do this many times especially for procedures).

Be sure to print out your ACGME case logs at least twice a year (We had to do this for our faculty advisors anyway). Keep your hardcopies safe.

I log my hours on Powerpoint and have done so since my second year.

I hope that this helps.

njbmd

 

[supercut]

That's a major problem at my program where there is such a lack of autonomy that even the senior residents often only opearate in the first assist role. Many times we aren't treated any differently than the attending would treat a PA (maybe part of the problem is that many of our attendings also spend some time operating at hospitals with no resident coverage and at those places do the case with a PA). If we round with an attending before cases in the am, they will often ask the team "who is helping me with this case?. (not who is doing this case or who is doing this case with me?)

My philosophy is that if all you are doing is bovieing between the attending's clamps, you aren't doing the case. If you aren't cutting and tying, but are holding the clamp and taking it off the vessel, you aren't doing the case.

I'll never forget as an intern, I double scrubbed the start of a whipple with a chief. I thought I'd get to "take out" the gall bladder (cuz every case I saw as a med student either the intern or I got to bovie out the gall bladder between the chief's clamps, while the attending stood on the sidelines). I was shocked to see that the chief was bovieing between the attendings clamps to get the gall bladder out.

We haven't been given any set of guidelines for our program as to how much you need to do to log a case. All I can say is, at the start of my PGY 3 year, after having done a breast rotation as PGY2, I only have 6 (out of 25 needed) for the skin, soft tissue and breast category. Because often as PGY 1 and 2 I was only holding retractors. And because all the wire localization biopsys don't count as breast cases, and neither to partial mastectomies with SLNB. And most lap cases I'm still mostly a camera holder, or at most I take the gallbladder out of the fossa. (even if there is a med student...the poor student scrubs and does absolutely nothing!)

I'm also not clear how I'm ever going to learn to do hernias. Here they are considered PGY1 and 2 cases. And when you scub as PGY 1 or 2, you do make the incision, and are guided (boviing between attendings clamps) down to the cord. Then the attending dissects the hernia off the cord and ligates the sack, and cuts the mesh and starts to sew it on (resident role here is retraction or stabilaztion) Then the attending let you finish sewing on the mesh and close the layers. I've never seen or heard of a senior resident take a jr through a hernia, and when I asked one of our seniors (who was going directly into private practice and was thus "stealing" hernias from interns) if I he could take me through a hernia, I was told NO because if there is a recurrence that would damage the attendings reputation in the community!

Needless to say, I'm very puzzled as to how I'm ever going to get all my cases. I'm puzzled as to how my colleages come out OK (unless they are putting down surgeon JR when they are really first assisting, or unless I am getting treated differently than everyone else...though my evaulations generally are acceptable to good)

There are a few attendings who we work with who allow us to do enough to acutally truly claim surgeon jr role. The vast majority of attendings don't allow us to dictate...I've dicated exactly 3 op notes since day of PGY 1, so NJBMD's "I dictate I log it" rule doesn't work for me.

Since we have this thread going, any advice from those in a similar situation to mine would be welcome.

 

[Winged Scapula]

Another tip is to log *everything* you do in a case. Some attendings will code only one CPT code on the op record. It is permissible to log things your attending did not if you actually did them. For example, if you did an ex-lap, and lysed a bunch of adhesions, resected some small bowel, repaired some enterotomies, and took the appendix... the attending may just log the ex-lap, sb rsxn, and appy. You should log these codes, but also log the enterolysis, and enterotomy repairs. This is important because if you are low in a certain category toward the end of your residency, you can go back to the oplog and claim credit for a different CPT code.

Just to clarify - you cannot claim credit for more than 1 procedure/operation per patient per day. Thus even though I might do an ERCP, Whipple and feeding jejunostomy on the same patient on the same day, I can claim only 1 of these for ACS case logs.

However, as celiac plexus notes, it is a good idea to keep records of all your procedures, even those which do not "count" as major cases (toward the number required by the ACS), if you have accurate records and find yourself short nearing the end of your Chief year, you can delete one CPT in a category for which you have enough and substitute another procedure on that patient. In addition, as noted, if you want priviledges for these procedures (ie, like central lines, filters, ports) you will need a log of them even though they may not count for ACS.

FYI, for those who might find themselves short of Vascular procedures (which I did). Greenfield filters COUNT toward the Vascular total; its fairly easy (or should be) to get your IR guys to let you do a few.

I kept my cases logged in an Excel file on the med center Network; that way it was easy to log the case from any computer in the PACU or even the OR, if the patient was taking awhile to wake up. Then every few weeks or so, I would forward the file to our program coordinator so that she could update it in her program.

To the OP: its always hard to ascertain whether or not you did 50% of the case. MY feeling was that if a more senior resident was scrubbed, unless they were "taking me through" a teaching case, I was first assist. Unless the attending was basically doing the case (which happened from time to time), I was surgeon junior or Chief resident when I logged the case.

 

[Blade28]

I log my hours on Powerpoint and have done so since my second year.

I log all my hours too, but it's in a text file on my Treo (backed up on my laptop). Why do you use Powerpoint, just out of curiosity? (Excel would seem like a more natural choice.)

To the OP: its always hard to ascertain whether or not you did 50% of the case. MY feeling was that if a more senior resident was scrubbed, unless they were "taking me through" a teaching case, I was first assist. Unless the attending was basically doing the case (which happened from time to time), I was surgeon junior or Chief resident when I logged the case.

I use similar criteria when deciding how to classify my role - if there's an attending, a fellow/senior resident, and me, then I'll be FA. If it's just me and an attending/fellow/chief, and they're in the teaching role while I'm doing most of the work, then I'll be SJ.

I also log absolutely everything - every central line, I&D, lac repair, bedside PEG-J, etc. in addition to the usual big OR cases. I logged around 260 cases as an intern (in a top-heavy program!).

 

[njbmd]

I log all my hours too, but it's in a text file on my Treo (backed up on my laptop). Why do you use Powerpoint, just out of curiosity? (Excel would seem like a more natural choice.)

Hi there,
I meant Excel. I was talking to my fiance while typing an answer to the OPs question. On a beautiful Saturday off, the brain is not wanting to multi-task.

njbmd

 

[Blade28]

Wish I had the day off today (or tomorrow). Have rounds with the attending at 7 am on weekends (the attending also happens to be my advisor and our program director), so that means getting to the hospital at 4...and not getting home until 4. Ouch.

 

[Celiac Plexus]

Generally I will log as surgeon junior any case where it is just me and the attending. With the exception of a few cases my intern year where I didn't do much on a big case e.g. a gastric bypass I did... although it was just me and the attending, there was no question that I was FA... even though I dictated it!

If you are scrubbed in with another resident, I assume the senior resident will claim credit and dictate the case. However, many times the senior resident will "give" the case to me, and I agree with njbmd... if you dictate it you log it. Rarely I will be "given" a case by a chief resident when I did little more than suction and retract... in that case I just dictate it and log it as FA.

In response to supercut's post: we have a few attendings that will steal the case unless you take it over. In those cases you just have to ask for the instrument before the attending does, and then "just do it." Most attendings will not object if you know what to do.

My program, has its shortcomings for sure, but learning to operate is not one of them. Our program not only encourages residents to be somewhat agressive on the OR, but even frowns on those that are not. One of our gi attendings is known for a ritual she has for testing a resident's comfort/ability level... she sits down and reads the chart while you scrub in. You walk in to the room, and gown up, and she justs keeps reading, seemingly oblivious, just to see what you do... In the last month of my second year, we were doing a loop colostomy reversal, and I was done mobilizing the colostomy and was about to fire the TA stapler when she finally went to go scrub. The scrub nurse was whispering "come on man, hurry up, let's finish this case before she gets here.." For small cases like chemoports, and Greenfields, the attending doesn't scrub, and the middle level resident TAs the intern.

Sometimes it's a little stressful though, e.g. the time (also in my second year) I was told to start my first lap chole while the attending went to scrub in... he comes walking in the OR and I had just managed to get the camera in with a lot of help from the scrub nurse, and I was so nervous that I forgot we were doing a lap chole, and instead thought were doing a lap appy... my attending puts the other ports in quickly, and I am very carefully keeping the camera focused on the appendix... after a minute or two, my attending was like, "OK man, I agree that's a beautiful appendix, but can we take a look at the gall bladder now?" I still get busted on for that one...