Abstract
Purpose
The decrease in resident operative experience due to working-hour directives and sub-specialization within general surgery is the subject of growing debate. This study aims to examine how the numbers of colectomies used for resident training have evolved since the introduction of working-hour directives and to place these results within the context of the number of new general surgeons.
Methods
Based on the nationwide database of the Swiss association for quality management in surgery, all segmental colectomies performed at 86 centers were analyzed according to the presence or absence of residents and compared to national numbers of surgical graduates.
Results
Of 19,485 segmental colectomies between 2006 and 2015, 36% were used for training purposes. Residents performed 4%, junior staff surgeons 31%, senior staff surgeons 55%, and private surgeons 10%. The percentage performed by residents decreased significantly, while the annual number of graduates increased from 36 to 79. Multivariate analysis identified statutory (non-private) health insurance (OR 7.6, CI 4.6–12.5), right colon resection (OR 3.5, CI 2.5–4.7), tertiary referral center (OR 1.9, CI 1.5–2.6), emergency surgery (OR 1.7, CI 1.3–2.3), and earlier date of surgery (OR 1.1, CI 1.0–1.1) as predictors for resident involvement.
Conclusions
Only a low and declining percentage of colectomies is used for resident training, despite growing numbers of trainees. These data imply that opportunities to obtain technical proficiency have diminished since the implementation of working-hour directives, indicating the need to better utilize suitable teaching opportunities, to ensure that technical proficiency remains high.
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References
Watson DR, Flesher TD, Ruiz O, Chung JS (2010) Impact of the 80-hour workweek on surgical case exposure within a general surgery residency program. J Surg Educ 67(5):283–289. https://doi.org/10.1016/j.jsurg.2010.07.012
Schwartz SI, Galante J, Kaji A, Dolich M, Easter D, Melcher ML, Patel K, Reeves ME, Salim A, Senagore AJ, Takanishi DM Jr, de Virgilio C (2013) Effect of the 16-hour work limit on general surgery intern operative case volume: a multi-institutional study. JAMA Surg 148(9):829–833. https://doi.org/10.1001/jamasurg.2013.2677
Carlin AM, Gasevic E, Shepard AD (2007) Effect of the 80-hour work week on resident operative experience in general surgery. Am J Surg 193(3):326–329; discussion 329-330. https://doi.org/10.1016/j.amjsurg.2006.09.014
Businger AP, Laffer U, Kaderli R (2012) Resident work hour restrictions do not improve patient safety in surgery: a critical appraisal based on 7 years of experience in Switzerland. Patient Saf Surg 6(1):17. https://doi.org/10.1186/1754-9493-6-17
Schlachta CM, Mamazza J, Seshadri PA, Cadeddu M, Gregoire R, Poulin EC (2001) Defining a learning curve for laparoscopic colorectal resections. Dis Colon Rectum 44(2):217–222
Tekkis PP, Senagore AJ, Delaney CP, Fazio VW (2005) Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg 242(1):83–91
Barrie J, Jayne DG, Wright J, Murray CJ, Collinson FJ, Pavitt SH (2014) Attaining surgical competency and its implications in surgical clinical trial design: a systematic review of the learning curve in laparoscopic and robot-assisted laparoscopic colorectal cancer surgery. Ann Surg Oncol 21(3):829–840. https://doi.org/10.1245/s10434-013-3348-0
Moore J, Pellet A, Hyman N (2016) Laparoscopic colectomy and the general surgeon. J Gastrointest Surg 20(3):640–643. https://doi.org/10.1007/s11605-015-2943-8
Moloo H, Haggar F, Martel G, Grimshaw J, Coyle D, Graham ID, Sabri E, Poulin EC, Mamazza J, Balaa FK, Boushey RP (2009) The adoption of laparoscopic colorectal surgery: a national survey of general surgeons. Can J Surg 52(6):455–462
Prystowsky JB, Bordage G, Feinglass JM (2002) Patient outcomes for segmental colon resection according to surgeon’s training, certification, and experience. Surgery 132(4):663–670 discussion 670-662
Karanicolas PJ, Dubois L, Colquhoun PH, Swallow CJ, Walter SD, Guyatt GH (2009) The more the better?: the impact of surgeon and hospital volume on in-hospital mortality following colorectal resection. Ann Surg 249(6):954–959. https://doi.org/10.1097/SLA.0b013e3181a77bcd
Drolet S, MacLean AR, Myers RP, Shaheen AA, Dixon E, Buie WD (2011) Elective resection of colon cancer by high-volume surgeons is associated with decreased morbidity and mortality. J Gastrointest Surg 15(4):541–550. https://doi.org/10.1007/s11605-011-1433-x
SIWF (2012) Facharzt für Chirurgie Weiterbildungsprogramm vom 1. Juli 2006 (revision 2. Mai 2012). http://www.fmh.ch/files/pdf19/chirurgie_version_internet_d.pdf. Accessed 10th of January 2017
AQC Website. Available via AQC. http://www.aqc.ch/Willkommen-bei-der-AQC.aspx. Accessed 11th of February 2018 2018
SIWF FMH-Ärztestatistik. Available via FNH. http://www.fmh.ch. Accessed 11th of February 2018 2018
Bevölkerungstatistik Schweiz. BFS. Available via BFS. http://www.bfs.admin.ch/bfs/de/home/statistiken/bevoelkerung.html. Accessed 11th of February 2018
Ahmed N, Devitt KS, Keshet I, Spicer J, Imrie K, Feldman L, Cools-Lartigue J, Kayssi A, Lipsman N, Elmi M, Kulkarni AV, Parshuram C, Mainprize T, Warren RJ, Fata P, Gorman MS, Feinberg S, Rutka J (2014) A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg 259(6):1041–1053. https://doi.org/10.1097/SLA.0000000000000595
Massarotti H, Rodrigues F, O’Rourke C, Chadi SA, Wexner S (2017) Impact of surgeon laparoscopic training and case volume of laparoscopic surgery on conversion during elective laparoscopic colorectal surgery. Color Dis 19(1):76–85. https://doi.org/10.1111/codi.13402
Schoetz DJ (2012) The American Board of Colon and Rectal Surgery: past, present, and future. Clin Colon Rectal Surg 25(3):166–170. https://doi.org/10.1055/s-0032-1322554
Krishna A, Russell M, Richardson GL, Rickard MJ, Keshava A (2013) Supervised surgical training and its effect on the short-term outcome in laparoscopic colorectal surgery. Color Dis 15(8):e483–e487. https://doi.org/10.1111/codi.12266
Renwick AA, Bokey EL, Chapuis PH, Zelas P, Stewart PJ, Rickard MJ, Dent OF (2005) Effect of supervised surgical training on outcomes after resection of colorectal cancer. Br J Surg 92(5):631–636. https://doi.org/10.1002/bjs.4935
Nijhof HW, Silvis R, Vuylsteke R, Oosterling SJ, Rijna H, Stockmann H (2017) Training residents in laparoscopic colorectal surgery: is supervised surgery safe? Surg Endosc 31(6):2602–2606. https://doi.org/10.1007/s00464-016-5268-0
Axt S, Johannink J, Storz P, Mees ST, Roth AA, Kirschniak A (2016) Surgical training in Germany: desire and reality. Zentralblatt fur Chirurgie 141(3):290–296. https://doi.org/10.1055/s-0042-102966
Acknowledgements
We thank the ACQ (Swiss association for quality management in surgery; Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie) for providing the data to perform this study.
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Käser, S.A., Rickenbacher, A., Cabalzar-Wondberg, D. et al. The growing discrepancy between resident training in colonic surgery and the rising number of general surgery graduates. Int J Colorectal Dis 34, 423–429 (2019). https://doi.org/10.1007/s00384-018-3209-1
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DOI: https://doi.org/10.1007/s00384-018-3209-1