Operative Case Volume Minimums Necessary for Surgical Training Throughout Rural Africa

Abstract

Background

Resident operative case volumes are an important aspect of surgical education, and minimums are required in Accreditation Council for Graduate Medical Education (ACGME) programs. Minimum operative case volumes for training do not exist in rural Africa. Our objective was to determine the optimal minimum operative case volume necessary for general surgery training in rural Africa.

Methods

A cross-sectional census electronic survey was conducted among faculty (N = 24) and graduates (N = 56) of Pan-African Academy of Christian Surgeons training programs. Three equally weighted exposures (median minimum case volume suggested by participants, operative experience of prior graduates, and comparisons with ACGME minimums), adjusted from responses to targeted questions, were utilized to construct an optimal minimum operative case volume for training.

Results

Sixty-four surgeons were contacted and 40 (13 faculty, 24 graduates, and 3 graduates who became faculty) participated. All participants thought operative case minimums were necessary, and the majority (98%) felt current training adequately prepared surgeons for their setting. Constructed optimal case volumes included 1000 major cases with fewer required cases than ACGME in abdomen, breast, thoracic, vascular, endoscopy, and laparoscopy and more required cases than ACGME for alimentary tract, endocrine, operative trauma, skin and soft tissue, pediatric, and plastic surgery. Other categories (gynecology, orthopedics, and urology) were deemed necessary for surgical training, with regional differences. Prior graduates satisfied the overall, but not category-specific, proposed minimums.

Conclusions

The surveyed surgeons highlighted the need for diverse surgical training with minimum exposures. They described increased need for cases reflecting regional variations with a desire for more experience in categories less common at their institutions.

Appendices

Appendix 1: Survey: quantitative and qualitative questions to assess recommendations for operative experience in training

Construct	Question	Answer options
Necessity of case minimums or maximums for training	Should a surgical trainee be required to complete a minimum number of cases to finish training and earn a diploma? Should a surgical trainee have a limit on the maximum number of cases they may perform during their training?	Select one: Yes No Maybe Option for text to describe reasoning
If minimum required
Desired experience during training	Which cases do you think trainees should have more exposure in during training compared to their current experience?	Select up to 5 options:  Skin, soft tissue (major excision/graft for skin neoplasm, lymphadenectomy, radical excision soft tissue tumor, pilonidal disease, other major skin/soft tissue)  Breast  Head and neck (exclude thyroid and parathyroid; include tracheostomy, parotidectomy, excision of tumor and/or lesions)  Alimentary tract (esophagus, stomach, small and large intestine, appendix, anorectal)  Abdominal (biliary, hernia, liver, pancreas, abdominal abscess drainage, non-trauma exlap)  Vascular (includes amputations)  Endocrine (includes thyroid, adrenal, and parathyroid)  Endoscopy (EGD, colonoscopy, cystoscopy, etc.)  Thoracic surgery (thoracotomy, cardiac, lung, diaphragmatic hernia)  Pediatric surgery (exclude cases based only on age; include hernia <12 years, congenital abnormalities, malrotation, intussusception, oomphalocele, gastroschisis, TEF/atresia, imperforate anus, hirschsprungs, pyloric stenosis, wilms, hypospadias, orchiopexy)  Plastic surgery (cleft lip or palate, major reconstruction, skin grafting, burn debridement and/or grafting, reduction and/or stabilization of maxillofacial fractures)  Neurosurgery (excludes subdural or extradural hematoma from trauma)  Urology  Orthopedics  Obstetrics and gynecology  Laparoscopy  Other (write-in)
Determine the overall number of minimum cases necessary	What do you think is the minimum number of major cases a trainee should complete prior to graduating or earning a diploma?	Enter a number
Comparison with ACGME case minimums	The United States Accreditation Council for Graduate Medical Education (ACGME) sets a minimum number of cases for trainees to complete prior to qualification/graduation (# listed in parentheses for each category). Kindly indicate for each category whether you think that trainees in General Surgery training programs should have more, fewer, or the same number of required cases in your location	Select one of four options for each category:  My location should not require these cases for general surgery training  My location should have Fewer cases required than the US  The US and my location should have the same number required  My location should have more cases required than the  US  All ACGME case categories listed along with minimum number of cases
Determine the minimal number of cases required for training for each category	At your location, what do you think should be the minimum number of major cases a surgical trainee should complete as the operating surgeon to complete training and earn a diploma as a general surgeon?	Enter the number necessary for each category. United States averages, United States minimums, and PAACS averages from the case log experience were listed for each category Each category was listed
Case log validation	Question for the 20 trainees whose case logs were reviewed The following is a list of your cases from residency training, categorized into the ACGME case logs. Do you think this accurately reflects your experience during training?	The number of cases by category for the individual participant is listed Select an option Yes No Maybe Opportunity to describe why the case log does not describe the experience
Confidence in training	If Faculty, As a trainer, I am confident that a general surgeon who graduates from the training program, where I train, is ready to be a general surgeon in the setting he or she was trained If Graduate, After completing my training, I felt confident as a general surgeon to competently perform the necessary tasks I was given in my setting.	Select one Strongly disagree Disagree Somewhat disagree Neither agree nor disagree Somewhat agree Agree Strongly agree

Appendix 2: Shapiro–Wilks test for normality

Survey responses by category	Shapiro–Wilks p value
Overall minimum number	0.646
Skin and soft tissue	0.0003
Breast	0.019
Head and neck	0.513
Alimentary tract	0.004
Abdomen	0.948
Vascular	0.0012
Endocrine	0.992
Operative trauma	<0.0001
Thoracic	0.014
Pediatric surgery	<0.0001
Plastic surgery	0.988
Basic laparoscopy	0.00009
Complex laparoscopy	<0.00001
Urology	0.15531
Orthopedics	0.615
OB/GYN	<0.0001
Upper endoscopy	0.00002
Lower endoscopy	0.153

Appendix 3: Recommendations from survey participants’ responses about the need for case volumes at their location of practice in comparison with ACGME case minimums. The case categories with more desired volumes (top 5) and least desired volumes in comparison with the ACGME case volumes (bottom 5) are displayed

	ACGME-defined minimum case volume	PAACS median number of cases from the trainee case log	None (0)	Fewer (1)	Same (2)	More (3)	Score**
Recommend more cases
Gynecology	0	120	0	1	1	31	2.91
Urology	0	112	0	0	4	29	2.88
Operative trauma	10	58	0	0	5	28	2.85
Orthopedics	0	188	1	0	2	30	2.85
Pediatric surgery	20	74	0	1	7	25	2.73
Recommend fewer cases
Liver	5	4	3	11	15	4	1.61
Vascular	50	47	2	13	17	1	1.52
Biliary	85	19	1	16	15	1	1.48
Basic laparoscopy	100	10	2	16	13	2	1.45
Complex laparoscopy	75	2	7	16	7	3	1.18

1. *“Score” calculated by averaging the points assigned to each category from each participant to provide a ranking relative to other case categories