surgical numbers

[OphthoBean]

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In another thread someone said "some places say you get 150 cataracts but they count standing in the corner and watching as a case"

Is this really true?

At your institution at what point during a routine PKE c IOL are you considered the primary surgeon if you take over? Is it any phaco? IA? IOL placement? Wound construction? The whole case? Standing in the corner? Just wondering.

 

[Retinamark]

Yes, it's true. There is wide variation on in different places to what constutites "primary surgeon".

At my program, it's usually when you do half or 2/3 of the case. If you are aggressive, you can be more lenient when counting.

You can't say you have "done" a procedure, until you can do the entire thing. If you've done most of the case for 30 cases, but have never done a rhexis, you still can't do a cataract operation. That's a total of 0, not 30.

Being "lenient when counting" is bending the truth isn't it.
I'd be wary of telling someone you have done more cases than you really have, because then they will expect you to be better than you are, which can only make you look bad.

Alternatively though, it can be a way of getting more surgery, by making your supervisor feel more comfortable about letting you do the case. It is a fine balance.

 

[GlaucomaMD]

I wouldn't consider one to have done the case unless you do the WHOLE case, from draping, opening, to closing and taking the drape off!

I'd be embrassed to have my residents say they did XXXX number of cases unless I let them actually do the whole cases.

If there are residency programs that are giving misleading numbers, they should be exposed...

Just my 2 cents.

 

[Andrew_Doan]

I wouldn't consider one to have done the case unless you do the WHOLE case, from draping, opening, to closing and taking the drape off!

I'd be embrassed to have my residents say they did XXXX number of cases unless I let them actually do the whole cases.

If there are residency programs that are giving misleading numbers, they should be exposed...

Just my 2 cents.

I think there are programs that advertise high numbers to look good to applicants. For instance, the minimum number of cataracts required for each resident is 45 Class 1 cases. However, some programs may advertise the Class 1 + Class 3 cases to make it seem that the resident is involved in many cases.

Also, to count as Class 1, the ACGME states that the resident must do 51% or more of the case.

I think Class 1 (primary surgeon) and Class 3 (assistant surgeon) participation have important roles in resident training.

 

[Eyesore]

I wouldn't consider one to have done the case unless you do the WHOLE case, from draping, opening, to closing and taking the drape off!

I'd be embrassed to have my residents say they did XXXX number of cases unless I let them actually do the whole cases.

If there are residency programs that are giving misleading numbers, they should be exposed...

Just my 2 cents.

Now this is just going overboard! I think a good rule of thumb is that the case has to count as a class 1 for somebody (resident or attending). If the resident did the whole case and the attending put in 1 stitch, should that not count as a class 1 for the resident? If not, then should the class 1 go to the attending? (Obviously the attending doesn't need to count class 1 etc, this is just for illustration purposes.) For an outside observer, does putting in 1 stitch qualify as getting a class 1 for the case? If not, then who gets credit for the case? A case was done, so somebody should get credit. That is why ACGME counts a class 1 as a case where someone did 51 percent or more of the case. Obviously, what constitutes most of the case is dependent on individual interpretation and that is not so cut and dry. I just disagree with the whole prep and drape required to count as a case. Come on, if the attending puts in the lid speculum and the resident does the whole case, then it doesn't count as a class 1? Nonsense! Just my 2 cents.

 

[Retinamark]

I think you have to do all of the IMPORTANT parts of the case. I agree with your speculum analogy.
However if you have done 95% of 10 cases, but can't do a capsulorhexis, you can't say you can do the procedure & your count should be zero.

If you do 51% of a case, but the attending does the rhexis, & removes the nucleus, how can you say you have done the case? Would you want to fly with a pilot who claims to have done 100 flights, but has never done the landing part?? 🙂

 

[Andrew_Doan]

I think you have to do all of the IMPORTANT parts of the case. I agree with your speculum analogy.
However if you have done 95% of 10 cases, but can't do a capsulorhexis, you can't say you can do the procedure & your count should be zero.

If you do 51% of a case, but the attending does the rhexis, & removes the nucleus, how can you say you have done the case? Would you want to fly with a pilot who claims to have done 100 flights, but has never done the landing part?? 🙂

The training of residents is accomplished in parts. For instance, as a PGY-2, I learned to fold the IOL and insert on numerous cases. Then I learned how to I&A the cortical material. Then I learned how to I&A, insert the lens, and close the wound. As a PGY-3, I did many capsulorhexi before completing a case from start to finish. I think there were 50 cases where I only did the capsulorhexis. But I finished the PGY-3 year with 26 Class 1 cases. Now, as a PGY-4, I'm finishing a rotation where I've done over 40 Class 1 cases.

For the most part, cataract surgery is one of the surgeries that US residents will have done all the parts of and complete cases from start to finish.

 

[JennyW]

For the most part, cataract surgery is one of the surgeries that US residents will have done all the parts of and complete cases from start to finish.

Can you clarify this statement Dr. Doan? Your use of the phrase "for the most part" almost implies that there are residents graduating who haven't even done one case from start to finish.

Surely that's not the case.

Jenny

 

[Andrew_Doan]

Can you clarify this statement Dr. Doan? Your use of the phrase "for the most part" almost implies that there are residents graduating who haven't even done one case from start to finish.

Surely that's not the case.

Jenny

Some residents get booted.

 

[3rdSight]

Some residents get booted.

Ophthalmology is a fairly benign specialty. They usually don't fire residents. There are a few programs that the chairman is a wild beast and won't hesitate to do so if she/he doesn't like the resident.

I know of a few cases where I have very reliable information. In some cases, the resident was an idiot. In other cases, the resident is evil or so lazy to the point that they should be fired but nothing is done about it. In some cases, the chairman is the evil beast.

 

[Retinamark]

I did a 1 week rotation in the UK. It seems that their cataract experience (if their claims are accurate) is much better than in the US. They claim to have done 300-500 cataracts...

That's about the same as Australia. In Melbourne, most would do 300 & good surgeons can do up to 400. I think the numbers in Brisbane are similar, but I'm not sure about Sydney.

(Those numbers are 100%, start to finish.)

 

[Eyesore]

Something I think that matters much more than numbers is the quality of teaching for those numbers. Having someone watch your every step and demanding you to do the case under precise specifications is much more valuable than someone indifferent staffing your case and letting you keep going, just because it is a "resident case." There are many ways to do these cases, many of which are not the safest. Someone that learns improper technique can do 150+ cases with unsafe technique and that, to me, is crap. Sure, most of the time the cases will turn out fine, but the chances of complications are higher, or the initial post-op outcome would be suboptimal. What I prefer is having attendings that will break down each step (from hand position, instrument approach, etc.) and explain why they do the steps that way. Each step matters and the rest of the case builds on what you did or did not do on the early steps. After this, you learn different methods from different attendings and then combine it in a way that works best for you.

The bottom line is that applicants should try to look beyond the numbers. Someone who did 70 cases could be much safer than someone who did 150 depending on the quality of teaching (and, of course, individual ability).

 

[Retinamark]

Something I think that matters much more than numbers is the quality of teaching for those numbers. Having someone watch your every step and demanding you to do the case under precise specifications is much more valuable than someone indifferent staffing your case and letting you keep going, just because it is a "resident case." There are many ways to do these cases, many of which are not the safest. Someone that learns improper technique can do 150+ cases with unsafe technique and that, to me, is crap. Sure, most of the time the cases will turn out fine, but the chances of complications are higher, or the initial post-op outcome would be suboptimal. What I prefer is having attendings that will break down each step (from hand position, instrument approach, etc.) and explain why they do the steps that way. Each step matters and the rest of the case builds on what you did or did not do on the early steps. After this, you learn different methods from different attendings and then combine it in a way that works best for you.

The bottom line is that applicants should try to look beyond the numbers. Someone who did 70 cases could be much safer than someone who did 150 depending on the quality of teaching (and, of course, individual ability).

I totally agree with that. My first 300 cases were totally supervised, with an attending always scrubbed in. It's only once you get to final year that they sit in the corner & play on their laptop or talk to the anaesthetist. They are still always in the room though, it is hospital policy in virtually every hospital in Australia that there must always be an attending present for every case.

 

[Visioncam]

Something I think that matters much more than numbers is the quality of teaching for those numbers.....

This is very true. I was going to start a post on this topic but kept putting it off.

When people ask me about residency programs, one thing that is not easily learned by the applicants is whether the program has at least 2 excellent cataract surgery teachers. Some programs have them and some do not. An attending with poor teaching skills might only know how to say "just do it" and not know why the resident's technique is awkward. Even if medical students find out who is a good teacher, that person might leave by the time they learn cataract surgery.

 

[2020]

I have seen some data with my own eyes and it conflicts with the numbers advertised during the interview days. Be careful!