Surgical numbers in residency

[GasAttendant]

What would be good numbers to strive for during each year of residency?
How many surgical cases should you have by the end of 3rd year?
What types of cases should each year be doing?
Or just, what was/is your experience with residency surgical numbers and types of cases?

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[MortonExtension]

More numbers don’t always mean better program. Some programs double/triple scrub, residents don’t touch the patient and the resident wasn’t actively participating.

Focus on programs where the residents are mainly doing the cases or at least given the chance to do the case. These programs usually have decent numbers as well

 

[GasAttendant]

I was trying to avoid a long rambling post. I definitely understand that. I’m just looking for some example hard numbers to compare to my experience.

 

[Retrograde_Nail]

I was trying to avoid a long rambling post. I definitely understand that. I’m just looking for some example hard numbers to compare to my experience.

I looked up my old numbers from residency. Did a high powered residency.

1288 surgical cases
2266 procedures

Never did a fellowship.

I do everything from toenails to TARs and everything in between. Supplement your experience with courses. Do lots of courses during residency and after as well.

 

[Feli]

1000+ procedures (with legit logging) should be bare minimum.

You want as much volume and variety as possible. Every program will have tons of amps and pus, but is there a lot of bunions, trauma, real recon? You want to see - and do - Achilles dissect, lateral hindfoot, medial hindfoot, lateral ankle, anterior ankle, scopes, heel surgery, etc etc etc approaches over and over. It doesn't matter exactly what procedure you're doing as techniques and implants change, but you just want a ton of instrument/surgery time to gain fundamentals.

Clinic and pus/amp surgery and hospital consults are the easy parts... first year stuff. If that's the "emphasis" of a program or most of their RRA is diabetic stuff, it's a below average program. Try to find a program that just has a good volume of trauma and elective recon (and doesn't quad scub all of it!). There should be some academics to help pass boards and research available, but the main goal is high volume and diversity of surgery cases.

Avoid those programs with few RRA/good attendings (even if that one attending/director is awesome, those programs should really be backups at best). You want a program with competent alumni and a good and varied "depth chart" of attendings bringing cases to the program.

 

[Adam Smasher]

I'm sure I'm on the low end compared to other posters here, but I graduated with about 600 cases. If I could have gotten more I surely would have. Doing courses and sawbones helps. Numbers are a simple metric for credentialing but there's an emerging tendency to look at surgical training benchmarks which ought to matter more assuming we're capable of taking a hard look in the mirror at ourselves.

Anyway, I am what I am, I do simple cases efficiently, consistently, and profitably, so say what you will about that.

 

[Hybrocure]

I’d say aim for 1,000 procedures. Best experience will be doing them yourself though. I’d take a skin to skin bunion once over retracting for 20.

My program had some very good attendings doing big cases and I had some impressive logs (TAR, high level trauma, etc). Most often single scrubbed.

I basically retracted for those. Wouldn’t touch them as an attending with a 10 foot pole because I just don’t feel I learned enough to do it comfortably. Any case I’ve done with my hands skin to skin are the only ones I feel good doing as an attending. That’s just me. I don’t learn by watching I learn by doing.

You can be at a program w a lot of big names but unless they’re letting you actually do anything your mileage may vary.

 

[GasAttendant]

These are great, thanks everyone!

 

[Feli]

Notable difference between cases vs procedures...

1000 procedures should be goal (at least half - hopefully 2/3 of them - being as first assist). That will be available at less than half of programs... probably less than a third of pod residencies, depending how much double-scrub they do.
1000 cases (patients) would be exceedingly rare. Yes @Retrograde_Nail did it, but you will get that surgical volume at maybe 5% of podiatry programs.

CPME surgery minimums are 400 procedures (first + second assist) and 50 of them RRA. But yeah... obviously don't do the minimum. You should 2x or 3x that with diversity of cases and much hands-on... even more is better.

Logs can be inflated with logging more second-assist crap (and many programs do just that), but you really only want to even bother logging those second assists on RRA or rare cases. Good programs don't have time for residents triple/quad/etc scrubbing anything except perhaps very complex or rare cases. That 3+ people plus attending scrubbing in stuff is for basically student level or crummy programs only.

 

[bloxxeeey]

Notable difference between cases vs procedures...

1000 procedures should be goal (at least half - hopefully 2/3 of them - being as first assist). That will be available at less than half of programs... probably less than a third of pod residencies, depending how much double-scrub they do.
1000 cases (patients) would be exceedingly rare. Yes @Retrograde_Nail did it, but you will get that surgical volume at maybe 5% of podiatry programs.

CPME surgery minimums are 400 procedures (first + second assist) and 50 of them RRA. But yeah... obviously don't do the minimum. You should 2x or 3x that with diversity of cases and much hands-on... even more is better.

Logs can be inflated with logging more second-assist crap (and many programs do just that), but you really only want to even bother logging those second assists on RRA or rare cases. Good programs don't have time for residents triple/quad/etc scrubbing anything except perhaps very complex or rare cases. That 3+ people plus attending scrubbing in stuff is for basically student level or crummy programs only.

I went to a fairly high volume program and I'm just under 1600 procedures and slightly under 1000 cases. I certainly got a little lazy towards the end of 3rd year as well... This is all first assists.

 

[FutureDPM123]

Bare minimum: 700 procedures

Although, 700 skin to skin is better than 1000 or 2000 retracting cases

 

[Hybrocure]

Bare minimum: 700 procedures

Although, 700 skin to skin is better than 1000 or 2000 retracting cases

200 skin to skin is better than 2000 retracting cases. If that wasnt the case scrub techs would be operating better than the docs

 

[CleanDryandIntact]

200 skin to skin is better than 2000 retracting cases. If that wasnt the case scrub techs would be operating better than the docs

 

[heybrother]

Haha. It is true. I've shaved variably 30-60 minutes off some of my procedures and I'm like - why couldn't this have happened in residency. It wouldn't have taken that many cases.

 

[Feli]

200 skin to skin is better than 2000 retracting cases. If that wasnt the case scrub techs would be operating better than the docs

Yes, concur.
This is why it's so important for residents to read, prep,
It will absolutely earn you more involvement if you show interest and knowledge.

BIG monster difference in showing up to a Lapidus just quietly and going to the side of the table after you glove up... versus taking the head of the table and starting to draw the incision line while asking about dorsal vs plantar plating or if attending ever does prox met osteotomies or mostly just Lapidus. Always take the head of the table... possible exception to very start of pgy1 or if it's a real good attending or tough case where you actually would do better learning by watching them.

Most of my attendings (and me, when worked with residents) would typically ask a question or two to see if the resident was prepped, and then they'd let them go until they were clearly stuck or going slow. I would finish the case at that point. A few would have the resident do either the soft tissue (dissect/closure) or the bone/tendon middle/.main work, but I think it's better to just let resident or attending get in the groove and only have one switch point if possible. Jmo that it's stupid to have those cases with "you do this part, then I'll do that... now you do X, back to attending for Y, now I throw a screw, now you try a screw, back to resident to close"... that's just inefficient and hard to gain any real momentum.

But yeah, always take the head of the table. Also, remember n+7... n is the number you've really scrubbed. n+7 is what you tell attending if they ask.

It's also why crap residency programs are crap residency programs.
In addition to too few cases and attendings, they typically have attendings who aren't very good themselves and are afraid to pass the knife and/or not very good to learn from - because they still need more reps/learning themselves. The attendings also usually know they have fairly low gpa/aptitude residents and will tend to do most of the surgery work themselves for that reasoning. It's a bad ongoing cycle.

 

[Feli]

Haha. It is true. I've shaved variably 30-60 minutes off some of my procedures and I'm like - why couldn't this have happened in residency. It wouldn't have taken that many cases.

We also have the issue that most DPM's first job (or nearly any DPM job) isn't exactly teeming with surgery.
It typically takes time to get privilegs at ASC/hospitals, see patients... usually at least a few months after residency before first case. There is often the owner or other group DPMs taking most of the "good stuff" with the new associate getting scraps. Add to that lack of early chemistry with the OR team, and it can be slow goings for the first year or so out of pod training.

It's far from Ortho or GenSurg or OB or most MDs where they come out and have a long list of patients waiting for surgery (and pick up many more surgeries on-call). On a lot of MD/DO surgeon clinic days, half - or more- of their patient visits are pre/post op... while midlevels see most of the non-op half.

Podiatry varies by office type, but it's usually 5-10% of office visits being surgical patients in most areas. I definitely can't think of any MD surgical specialty that has such a low percent of office visits being surgery (perhaps some semi-retired OB or ENT... or gen/plastics who does wound care... but those are far outside the norms).

Our clinic and esp surgical volume/diversity (and grad efficiency) leaves a lot to be desired, even at fairly good pod residencies. Our surgery % as attendings is stupid low as we insist all podiatrists are "three year surgery trained." It makes little sense on many levels... supply/demand, quality of training, quality for competence. It would be like if all dentist did wisdom teeth... you'd have each doing 1 or 2 cases per month... instead of oral surgeons doing 5-10 cases per week.

 

[Hybrocure]

We also have the issue that most DPM's first job (or nearly any DPM job) isn't exactly teeming with surgery.
It typically takes time to get privilegs at ASC/hospitals, see patients... usually at least a few months after residency before first case. There is often the owner or other group DPMs taking most of the "good stuff" with the new associate getting scraps. Add to that lack of early chemistry with the OR team, and it can be slow goings for the first year or so out of pod training.

It's far from Ortho or GenSurg or OB or most MDs where they come out and have a long list of patients waiting for surgery (and pick up many more more on-call). On a lot of MD/DO surgeon clinic days, half - or more- of their patients are pre/post op... while midlevels see most of the non-op half.

Podiatry varies by office type, but it's usually 5-10% of office being surgical patients in most areas. I definitely can't think of any MD specialty that has such a low percent of office visits being surgery (perhaps some semi-retired OB or ENT... or gen/plastics who does wound care... but those are far outside the norms).

Our clinic and esp surgical volume/diversity (and grad efficiency) leaves a lot to be desired, even at fairly good pod residencies. Our surgery % as attendings is stupid low as we insist all podiatrists are "three year surgery trained." It makes little sense on many levels... supply/demand, quality of training, quality for competence. It would be like if all dentist did wisdom teeth... you'd have each doing 1 or 2 cases per month instead... of oral surgeons doing 5-10 cases per week.

Agreed. Not to mention a run of the mill podiatry practice is likely getting few “healthy” surgical candidates. Sure there’s a lot of old, diabetic people who “could use” a recon, fusion etc.

But you’d be a dummy to cut on all those fresh out of residency. Yet a lot do. Because, well,

Podiatry.

 

[MicroPod]

We also have the issue that most DPM's first job (or nearly any DPM job) isn't exactly teeming with surgery.
It typically takes time to get privilegs at ASC/hospitals, see patients... usually at least a few months after residency before first case. There is often the owner or other group DPMs taking most of the "good stuff" with the new associate getting scraps. Add to that lack of early chemistry with the OR team, and it can be slow goings for the first year or so out of pod training.

It's far from Ortho or GenSurg or OB or most MDs where they come out and have a long list of patients waiting for surgery (and pick up many more surgeries on-call). On a lot of MD/DO surgeon clinic days, half - or more- of their patient visits are pre/post op... while midlevels see most of the non-op half.

Podiatry varies by office type, but it's usually 5-10% of office visits being surgical patients in most areas. I definitely can't think of any MD surgical specialty that has such a low percent of office visits being surgery (perhaps some semi-retired OB or ENT... or gen/plastics who does wound care... but those are far outside the norms).

Our clinic and esp surgical volume/diversity (and grad efficiency) leaves a lot to be desired, even at fairly good pod residencies. Our surgery % as attendings is stupid low as we insist all podiatrists are "three year surgery trained." It makes little sense on many levels... supply/demand, quality of training, quality for competence. It would be like if all dentist did wisdom teeth... you'd have each doing 1 or 2 cases per month... instead of oral surgeons doing 5-10 cases per week.

When I was on trauma service in residency the ortho team had just hired a new orthopedist fresh out of trauma fellowship. His first day on call, first consult an auto-pedestrian accident came in. All four extremities had injuries: left humerus open fracture (basically hanging on by a thread), right wrist open fracture, left femur open fracture and right ankle open fracture. He had a bunch of other injuries as well that I can’t remember. Imagine something like that on your first day lol.

 

[Hybrocure]

When I was on trauma service in residency the ortho team had just hired a new orthopedist fresh out of trauma fellowship. His first day on call, first consult an auto-pedestrian accident came in. All four extremities had injuries: left humerus open fracture (basically hanging on by a thread), right wrist open fracture, left femur open fracture and right ankle open fracture. He had a bunch of other injuries as well that I can’t remember. Imagine something like that on your first day lol.

I think a lot of pods who fight with ortho never worked with orthos who do polytrauma. This is how patients roll into level 1 trauma centers and why they go to ortho. A lot of the time they have other injuries going on other than just the ankle