Training a New Generation of Breast Surgeons: Are We Succeeding?

Background

Society of Surgical Oncology (SSO)-approved fellowships in Breast Oncology began training fellows in 2004. Here we ascertain methods of evaluating and improving the fellowship experience through fellowship alumni experience.

Methods

We conducted an electronic survey of fellowship graduates to learn perceived successes and weaknesses of their fellowship training, as well as their current practice experiences. Our electronic survey focused on their preparedness for practice, their job opportunities, and their use of image-guided biopsies in practice.

Results

Between 2005 and 2009, 142 fellows graduated and received our survey; 85 (60%) responded. Although 98% of graduates though that they were well prepared by their fellowship for performing breast cancer surgery, fewer thought that they were well prepared to perform oncoplastic techniques (53%), ultrasound (39%), and ultrasound-guided biopsies (28%). Nevertheless, many acquired additional training, and 63% were performing ultrasound-guided biopsies in practice. The majority (76%) were performing breast surgery exclusively, with 14% identifying themselves as director of a breast center and only 29% describing themselves as being in private practice??the rest being employed at a hospital or university. Only 8% of respondents were disappointed with the job market, and 67% stated they had received at least three job offers; 82% were satisfied in their current job.

Conclusions

SSO breast oncology fellowships appear to be training confident, well-prepared graduates with good job outlooks, and many are achieving leadership positions. Deficiencies in sonography training, some advanced surgical techniques, and administrative experiences should be addressed by program directors as graduates do perceive the need for such training.     

Update Experience of Surgery for Acute Limb Ischaemia in a District General Hospital – Are We Getting Any Better?

INTRODUCTION

The aims of this study were to audit results of a 10-year experience of surgery for acute limb ischaemia (ALI) in terms of limb salvage and mortality rates, and to compare results with a historical published series from our unit.

PATIENTS AND METHODS

All emergency operations performed during the period 1993–2003 were identified from theatre registers and patient notes reviewed to determine indications for, and outcome of, surgery. Data were compared to a similar cohort who underwent surgery from 1980 to 1990.

RESULTS

There was a 33% increase in workload from 87 to 116 patients between the two time periods. The number of patients with idiopathic ALI reduced (24% versus 4%; P < 0.05), and there were fewer smokers (71% versus 39%; P < 0.05) and a greater number of claudicants (17% versus 35%; P < 0.05) in those treated from 1993–2003. Latterly, more patients underwent pre-operative heparinisation (33% versus 80%; P < 0.05), received prophylactic antibiotics (14% versus 63%; P < 0.05), and had anaesthetic presence in theatre (46% versus 88%; P < 0.05). There was also a reduction in local anaesthetic procedures (80% versus 41%; P < 0.05). Despite increased pre-operative (15% versus 47%; P < 0.05) and on-table imaging (0% versus 16%; P < 0.05) technical success did not improve. Whilst complication rates were identical at 62%, there were fewer cardiovascular complications in the recent cohort. The 30-day mortality rate for embolectomy fell from 45% to 33%. Multivariate analysis revealed age > 70 years, prolonged symptom duration, ASA score ≥ III, lack of prophylactic antibiotics, absence of an anaesthetist, and operations performed under local anaesthetic to be associated with increased risk of mortality. Factors adversely affecting limb salvage included prolonged duration from symptom onset to operation, and a history of claudication or smoking.

CONCLUSIONS

Despite improvements in pre- and peri-operative management, arterial embolectomy/thrombectomy remains a procedure with a high morbidity and mortality. Further attempts to improve outcome must be directed at early diagnosis and referral as delay from symptom onset to surgery is a major determinant of outcome.     

Do General Surgery Applicants Really Want to be General Surgeons?

OBJECTIVE: The authors sought to compare categorical general surgery applicants with applicants in other specialties regarding their final specialty-choice ranking for residency positions. METHOD: The authors analyzed the 2004-match year applicant-pool data from the Electronic Residency Application Service and Common Application Service as well as rank-list data from the National Resident Matching Program (NRMP), the Urology Match Program, and the San Francisco Matching Program for 20 different specialties. Two-tailed chi-square tests measured differences between the proportions of applicants who ultimately ranked programs in categorical general surgery and each of 19 other specialties and between the proportions of U.S. students who ranked categorical general surgery and each of 19 other specialties as a non-preferred choice. A Bonferroni-adjusted alpha was set at 0.0013 to reduce the likelihood of a type I error. RESULTS: The proportion of applicants ranking each specialty ranged from 42% (786/1859) in pathology to 91% (282/31l) in neurological surgery. The proportion of categorical general surgery applicants ranking categorical general surgery programs was 51% (2004/3900), which was significantly lower than the proportions ranking 12 of 19 other specialties (each p < 0.001). Of the 2004 categorical general surgery applicants ranking categorical general surgery programs, 278 (278/2004, 14%) ranked categorical general surgery as a non-preferred specialty. Among 1230 U.S. students ranking categorical general surgery programs, 144 (12%) did so as a non-preferred specialty-a proportion significantly higher compared with U.S. students ranking 15 of 19 other specialties as non-preferred (each p < 0.001). CONCLUSIONS: In 2004, the categorical general surgery applicant pool was relatively uncommitted to the specialty of general surgery. The number of applicants ranking categorical general surgery as a non-preferred specialty was likely even higher than these data indicate, as unmatched applicants in non-NRMP matches who then ranked categorical general surgery programs in the NRMP were tabulated by the NRMP as having ranked categorical general surgery as their preferred specialty.     

Experimental Surgery: Where Are We Going?

The United States has a long history of leadership in cardiovascular surgery, from the pioneering efforts of Blalock, Harken, Gibbon, Lillehei, and Bailey in the 1940s and 1950s to the work of Debakey, Cooley, Shumway, and Kantrowitz in the 1960s and Rastelli and Olsen in the 1970s. The experimental and clinical literature is filled with United States surgeons developing breakthrough techniques, many of which are still in use today. The works of our own Markowitz awardees are a litany of the contributions of cardiovascular research surgeons. Recently, the focus has shifted, I believe, away from the United States to other countries such as Japan, with surgeons such as Kuno, or France, with the renowned group led by Carpartier.     

Anastomotic Failure in Colorectal Surgery: Where Are We at?

Anastomotic leak (AL) can be a devastating complication in colorectal surgery. While it is less frequent in the modern era, it still results in significant morbidity and mortality, prolonged hospital stays and increases the costs and demands on health services. There is inevitable interplay between patient physiology and technical factors that predispose a patient to AL. Obesity, preoperative total proteins, male gender, ongoing anticoagulant treatment, intraoperative complication and number of hospital beds have been identified as independent risk factors. This has led to an online risk calculator for AL. Non-steroidal anti-inflammatory drugs and neoadjuvant chemoradiotherapy have also been implicated, but no significant evidence has yet been found to support causation. In addition, technical factors such as type of anastomosis, mechanical bowel preparation, drains, omentoplasty and faecal diversion have failed to show significant differences in AL rates. Early diagnosis and intervention in AL is essential in reducing the rates of morbidity and mortality. Clinical assessment has high sensitivity but low specificity and should be used in combination with imaging techniques to get a diagnosis. C-reactive protein is also a useful marker. The management will depend on the grade of AL and the clinical state of the patient. Management options include conservative measures such as antibiotics and/or percutaneous drainage to more invasion procedures such as open drainage and/or Hartmann’s procedure. In conclusion, ALs will forever pose challenges to the surgeon in diagnosis and management. It is often the yardstick by which each surgeon is measured and is the source of significant morbidity to patients and health care services worldwide. As a result, a low threshold for investigation and intervention is mandatory to ensure better outcomes and lower overall mortality and morbidity.     

Endovascular Training of Vascular Surgeons: Have We Made Progress?

The rapid evolution of catheter-based technologies during the last 5 years has created a critical need for development of effective resident level and postgraduate education programs in both open and endovascular techniques and associated cognitive and clinical skills. Currently, significant variability exists in endovascular training formats and in the number of endovascular procedures performed during the course of a graduate or postgraduate program. Little information on the quality of these programs exists and in the subsequent practice patterns of the trainees. This report reviews recommended credentialing requirements, training paradigms, and the growing experience of vascular surgical trainees since 2000.     

Does Resident Experience Affect Outcomes in Complex Abdominal Surgery? Pancreaticoduodenectomy as an Example

Objectives

Understanding the factors contributing to improved postoperative patient outcomes remains paramount. For complex abdominal operations such as pancreaticoduodenectomy (PD), the influence of provider and hospital volume on surgical outcomes has been described. The impact of resident experience is less well understood.

Methods

We reviewed perioperative outcomes after PD at a single high-volume center between 2006 and 2012. Resident participation and outcomes were collected in a prospectively maintained database. Resident experience was defined as postgraduate year (PGY) and number of PDs performed.

Results

Forty-three residents and four attending surgeons completed 686 PDs. The overall complication rate was 44 %; PD-specific complications (defined as pancreatic fistula, delayed gastric emptying, intraabdominal abscess, wound infection, and bile leak) occurred in 28 % of patients. The overall complication rates were similar when comparing PGY 4 to PGY 5 residents (55.3 vs. 43.0 %; p?>?0.05). On univariate analysis, there was a difference in PD-specific complications seen between a PGY 4 as compared to a PGY 5 resident (44 vs. 27 %, respectively; p?=?0.016). However, this was not statistically significant when adjusted for attending surgeon. Logistic regression demonstrated that as residents perform more cases, PD-specific complications decrease (OR?=?0.97; p?<?0.01). For a resident's first PD case, the predicted probability of a PD-specific complication is 27 %; this rate decreases to 19 % by resident case number 15.

Conclusions

Complex cases, such as PD, provide unparalleled learning opportunities and remain an important component of surgical training. We highlight the impact of resident involvement in complex abdominal operations, demonstrating for the first time that as residents build experience with PD, patient outcomes improve. This is consistent with volume–outcome relationships for attending physicians and high-volume hospitals. Maximizing resident repetitive exposure to complex procedures benefits both the patient and the trainee.