Surgical Numbers Question

[hightower]

I was browsing some surgical numbers of the residents of one program and noticed a trend (or lack thereof). The 1st year resident had more "B" cases than "C". Ok no big deal right? After all its just the first year. I was expecting an upward trend in the second year but no, the 2nd year resident had far more "B" than "C" cases as well. And you guessed it, the 3rd year resident also had more "B" than "C" cases too.

My thought was that as you progress in a good surgical program you would gain more confidence from your attendings and take the reigns on the majority of the cases you scrub on. Maybe that is wishful thinking? Anyway, is it common to have more "B" than "C" cases as a third year resident, or would you be concerned about such a program?

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[347932]

I was browsing some surgical numbers of the residents of one program and noticed a trend (or lack thereof). The 1st year resident had more "B" cases than "C". Ok no big deal right? After all its just the first year. I was expecting an upward trend in the second year but no, the 2nd year resident had far more "B" than "C" cases as well. And you guessed it, the 3rd year resident also had more "B" than "C" cases too.

My thought was that as you progress in a good surgical program you would gain more confidence from your attendings and take the reigns on the majority of the cases you scrub on. Maybe that is wishful thinking? Anyway, is it common to have more "B" than "C" cases as a third year resident, or would you be concerned about such a program?

If the program is getting you the appropriate number of "C" cases, why even worry about it?

 

[hightower]

If the program is getting you the appropriate number of "C" cases, why even worry about it?

Good answer, that is most important I agree. I just didn't know if it would be concerning being scrubbed on more B's than C's when you are a third year resident. Do 3rd year residents guide the 1st and 2nd years through procedures in some programs? That could account for it I guess. I was just thinking there would not be much reason for a 3rd year resident not to do the majority of cases he/she was scrubbed in on unless they are not very competent surgeons or they are just teaching the younger residents. Or another possibility, the attendings do not give the knife up easily. I would be wary if it were the first or last reasons I mentioned. Bottom line is that I just don't know what the norm is for numbers and their breakdown hence my question.

 

[347932]

The best way to get the answers you need is to ask the residents at the programs you are interested in.

Or another possibility, the attendings do not give the knife up easily.

Attendings that don't give up the knife easily may just be the ones that can teach you the most and have the highest expectations as to the quality of the residents they train. Think about that for a sec or two.

 

[jonwill]

I was browsing some surgical numbers of the residents of one program and noticed a trend (or lack thereof). The 1st year resident had more "B" cases than "C". Ok no big deal right? After all its just the first year. I was expecting an upward trend in the second year but no, the 2nd year resident had far more "B" than "C" cases as well. And you guessed it, the 3rd year resident also had more "B" than "C" cases too.

My thought was that as you progress in a good surgical program you would gain more confidence from your attendings and take the reigns on the majority of the cases you scrub on. Maybe that is wishful thinking? Anyway, is it common to have more "B" than "C" cases as a third year resident, or would you be concerned about such a program?

A couple thoughts on the above mentioned issue. It is important to look at numbers and that would raise somewhat of a red flag for me. However, I would hope they are still getting the minimum number of C's for graduation. The other thing to watch is how comfortable the 3rd year residents are when they do operate. If they seem very confident and do well, they are getting solid training. If they all constantly struggle on a day to day basis, I would be concerned. I ultimately chose my program because when I first started rotating, the 3rd years were so competent and confident in the OR and clinic, I thought they were attendings.

 

[Feli]

A couple thoughts on the above mentioned issue. It is important to look at numbers and that would raise somewhat of a red flag for me. However, I would hope they are still getting the minimum number of C's for graduation. The other thing to watch is how comfortable the 3rd year residents are when they do operate. If they seem very confident and do well, they are getting solid training. If they all constantly struggle on a day to day basis, I would be concerned. I ultimately chose my program because when I first started rotating, the 3rd years were so competent and confident in the OR and clinic, I thought they were attendings.

Yes, this is the bottom line. Look at the residents and SEE with your own eyes how much they get to do in the OR. Look at chief residents and see how smooth they operate. Even better: if possible, look at young attendings who graduated the program and see what kinda cases they're doing and how well they do them.

As for more B logs than C logs, that just means they double, triple, etc scrub a lot (only one resident can take a "C" log on each individual procedure... assuming the attending passes the knife for a decent 50+% of the case). That's not necessarily a bad thing to double scrub, but it does raise the question of "why"... esp if it's not very complex surgery. As was said, look at their overall numbers and see how they are.

Especially in the early months of the training year (ie July through Oct or so, it isn't always bad to double scrub - even on forefoot. Example: I'm a pgy3, but maybe if it's a day without rearfoot cases, then I'll go scrub a lapidus and hammertoes with my pgy2 or even pgy1 co-resident. I'm done with my numbers on that stuff and have been for awhile, but I might do the Lapidus if it's an inexperienced pgy1 with me, or if it's a pgy2, I'll just mostly watch as the pgy2 resident does the case or the attending teaches them. I will log mostly B procedures either way. In the end, OR time is OR time... I can learn by watching anatomy and technique, and as a resident who has done many of those procedures in the past couple years, I'm there to give pointers, assist, or take over if asked by the attending.

 

[Podfather]

A couple thoughts on the above mentioned issue. It is important to look at numbers and that would raise somewhat of a red flag for me. However, I would hope they are still getting the minimum number of C's for graduation. The other thing to watch is how comfortable the 3rd year residents are when they do operate. If they seem very confident and do well, they are getting solid training. If they all constantly struggle on a day to day basis, I would be concerned. I ultimately chose my program because when I first started rotating, the 3rd years were so competent and confident in the OR and clinic, I thought they were attendings.

Yes if the third years are competent and skilled then the system works. Not every residency is in a large teaching hospital where the patients expect care by a resident/fellow. Some are still in community hospitals where the patient went to an attendings office so they could do their surgery. If things go less than expected on too many of these patients, referrals drop and hence case numbers.

Sometimes I break the case into parts and set a goal for the resident to learn and gain experience on that part. Perhaps it's dissection or fixation. Also the B/C thing is ending but some programs are liberal or encourage a resident to log a C for MAV reasons where at my program it's a B.

 

[dtrack22]

Podfather,

Are we going to a first assist, second assist logging system this time around? I know it was in a draft of the latest guidelines but was left out of the final document (CPME 320 I think?).

 

[Podfather]

Podfather,

Are we going to a first assist, second assist logging system this time around? I know it was in a draft of the latest guidelines but was left out of the final document (CPME 320 I think?).

Yes. There are issues with that as well.

 

[hightower]

Yes, this is the bottom line. Look at the residents and SEE with your own eyes how much they get to do in the OR.

Thanks for the advice everyone. I will pay close attention during my externships. It is just hard at this point trying to pick 6-7 programs I want to visit without being able to be there to evaluate for myself. Even contacting students that have rotated through programs still leaves questions. Opinions vary so sometimes I look at things like numbers, and even those end up being subjective. The insight from this thread does help a lot. I guess I'll look at numbers with a grain of salt, since there is more than meets the eye behind them. I guess the good thing is that there are many solid programs out there these days, and as discussed in other threads the most important thing is that you find a program you can thrive in. Regardless, it still feels like a crap shoot when choosing exterships

 

[Feli]

Attendings that don't give up the knife easily may just be the ones that can teach you the most and have the highest expectations as to the quality of the residents they train. Think about that for a sec or two.

This is true, but only to an extent. It's great to have attendings with high standards and who protect their patients, but as a resident, you need the hands-on. If the residents consistently show up ill prepared, then don't let them scrub anymore. If they show up having reviewed the dissection, knowing the implants, etc, then let them get involved. It's that simple if you're a teaching attending. Residents can only learn so much from watching DVD/online videos, suturing practice, and cadaver dissection lab. The OR should be a place to learn, not just watch, retract, and dictate and write notes.

It's no small wonder why attendings who consistently don't pass much of the work end up as "first year" attendings very soon. No matter how complex the case, there's really no reason to deny a reasonably talented and prepared resident the opportunity for doing at least the non-critical parts of the case (incision/dissection, closure, casting, etc). If the attending can't pass at least those parts to residents - and eventually give them almost all the work once they've seen their competence in basic stuff - then why be a teaching attending?

 

[PADPM]

This is true, but only to an extent. It's great to have attendings with high standards and who protect their patients, but as a resident, you need the hands-on. If the residents consistently show up ill prepared, then don't let them scrub anymore. If they show up having reviewed the dissection, knowing the implants, etc, then let them get involved. It's that simple if you're a teaching attending. Residents can only learn so much from watching DVD/online videos, suturing practice, and cadaver dissection lab. The OR should be a place to learn, not just watch, retract, and dictate and write notes.

It's no small wonder why attendings who consistently don't pass much of the work end up as "first year" attendings very soon. No matter how complex the case, there's really no reason to deny a reasonably talented and prepared resident the opportunity for doing at least the non-critical parts of the case (incision/dissection, closure, casting, etc). If the attending can't pass at least those parts to residents - and eventually give them almost all the work once they've seen their competence in basic stuff - then why be a teaching attending?

Excellent post. In addition, it depends on not only the skill, but the attitude of the resident(s). Some of the residents I've encountered in the past have had the attitude that it was their "right" to scrub and perform a significant portion of the surgery, and that simply doesn't fly with me.