Vascular surgery training in general surgery residency programs: the Canadian experience

OBJECTIVES: Vascular surgery is traditionally considered a component of general surgery. There is growing evidence of improved patient outcome related to surgeon volume and vascular certification status. The American Board of Surgery in the United States, as well as until recently the Royal College of Physicians and Surgeons in Canada, requires that vascular surgery be considered an essential content area of general surgery training. This requirement is controversial. The purpose of this study was to describe experience and perceived competence in common vascular surgery procedures during general surgery residency training in Canada. METHODS: This web-based survey was conducted between January and June 2002. General surgery program directors (GSPDs), vascular surgeons involved in general surgery training programs (VSs), and senior general surgery residents (SRs) from the 13 English-speaking general surgery programs in Canada were surveyed. Questions were asked regarding which vascular surgery procedures are appropriate for general surgeons to perform, which procedures SRs are trained to perform, and which procedures SR intend to perform. RESULTS: The response rate was 62% for GSPDs, 57% for VSs, and 45% for SRs. Overall, 49% of SRs did not intend to perform any vascular procedures after training. GSPDs, VSs, and SRs indicated that most SRs should be and are trained to perform varicose vein surgery, leg amputation, and femoral embolectomy (P >.05). In addition, GSPDs, VSs, and SRs indicated that SRs should not be and are not trained to perform infrainguinal bypass grafting, carotid endarterectomy, or abdominal aortic aneurysm (AAA) repair (P >.05). There were significant differences with respect to ruptured AAA repair: 49% of SRs, 25% of PDs, and only 12% of VSs believe that general surgeons should be trained to perform ruptured AAA repair (P <.05). Overall, 76% of VSs believe SRs receive too little vascular training. CONCLUSION: There is similarity between GSPDs, VSs, and SRs with respect to vascular surgery training in Canadian general surgery programs. Vascular surgery training cannot be considered a component of general surgery. More rotations or fellowship training is required to become competent in management of common vascular surgery procedures. Perhaps this level of competence should not be an objective of general surgery training.     

Training general surgery residents in pediatric surgery: A Canadian survey

BACKGROUND/PURPOSE: The training of general surgeons in pediatric surgery is an important educational role of pediatric surgeons (PS). The authored surveyed this training process and the related expectations and perceptions of competence. METHODS: The authors surveyed all practicing members of the Canadian Association of Paediatric Surgeons (CAPS) in Canada, all general surgery program directors (PD), and all final year general surgery residents (GS). Questions included exposure to pediatric surgery, expected and perceived competence in managing common pediatric general surgical problems, and trainee practice intentions. RESULTS: Response rate to date was 51% from PS, 69% from PD, and 19% from GS. Sixty-seven percent of PS considered the exposure to pediatric surgery satisfactory, yet only 1 of 7 residents planning on pursuing general surgery felt adequately prepared. Trainees were expected to be competent in the conditions polled by 65% of PS and 74% of PD, yet only 38% of the trainees actually felt competent in them. The largest discrepancies were found for infant hernia, newborn colostomy, and cryptorchidism. Presence of a fellowship program and size of training program had no impact on perceived competence. CONCLUSIONS: Training of general surgeons in pediatric surgery varies across Canadian programs. Perceived resident competence often lags behind program and faculty expectations. These data can be used for directing educational priorities in general surgery programs.     

Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service

BACKGROUND: Dwindling operative opportunities in trauma care may have a detrimental impact on career satisfaction among trauma surgeons and on career attractiveness to surgical trainees. Addition of emergency general surgery may alleviate some of these concerns. STUDY DESIGN: The trauma service at our institution incorporated nontrauma emergency general surgery over a 3-year period. The institution's trauma registry and hospital perioperative database were queried. The changes in operative caseload are described. Current trauma faculty anonymously completed a Web-based questionnaire about the addition of emergency general surgery to the trauma service. RESULTS: Operations for trauma decreased in 2002 compared with 1999, despite a higher number of penetrating injuries and total trauma contacts. Nontrauma general surgery operations performed by trauma faculty increased in proportion to coverage provided by the trauma service. In 2002, 57% of all cases performed by trauma surgeons were emergency general surgery, which accounted for 32% to 74% of an individual surgeon's caseload. In anonymously completed Web-based questionnaires, current trauma faculty expressed satisfaction with the combined trauma and emergency general surgery model. CONCLUSIONS: The combined trauma and nontrauma surgery service increased operative caseloads and improved satisfaction of trauma surgeons. A comprehensive trauma and emergency general surgery service may be an attractive model for the future of trauma surgery and provide logistical and medical advantages to the emergency general surgery patient population.     

Choice of vascular surgery as a specialty: survey of vascular surgery residents, general surgery chief residents, and medical students at hospitals with vascular surgery training programs

PURPOSE: Under the direction of the Association of Program Directors in Vascular Surgery, a survey was mailed to vascular surgery residents (VSRs), general surgery chief residents (GS-CRs), and fourth-year medical students (MSs) to better define reasons why trainees do and do not choose vascular surgery as a career. METHODS: Questionnaires were mailed to all accredited VSR programs and their associated GS programs in the United States and Canada in 2001 (survey 1) and in 2003 (survey 2) and to 2 medical schools with VSR programs in 2001. A total of 197 VSRs, 169 GS-CRs, and 78 MSs responded (overall program response rate of 78% for VSRs, 46% for GSRs, 20% for MSs). A scoring system was assigned, with 1.0 the least important and 5.0 the most important reasons to choose or not choose vascular surgery. RESULTS: Technical aspects, role of mentors, and complex decision making involved in vascular surgery were the most important reasons that VSRs, GS-CRs, and MSs would choose vascular surgery as a specialty (average scores > or =4.0 for VSRs and GS-CRs; > or =3.5 for MSs). Responses of GS-CRs and VSRs did not vary significantly between surveys 1 and 2, except endovascular capabilities of vascular surgeons had a more important role in choosing vascular surgery, and future loss of patients to other interventionalists had a more important role in not choosing this specialty in the more recent survey of GS-CRs and VSRs. MSs identified lifestyle as a surgical resident (4.3) and as a surgeon (4.2) as the most important negative factors. A training paradigm consisting of 4 years general surgery + 2 years vascular surgery with a GS certificate was favored by 64% of GS-CRs and 48% of VSRs, compared with a paradigm of 5 years + 2 years with a general surgery certificate, which was favored by 29% of GS-CRs and 25% of VSRs, or 3 years + 3 years without a general surgery certificate, favored by 7% of GS-CRs and 27% of VSRs. Of note, 86% of MSs favored 3 years general surgery + 3 years vascular surgery or 2 years general surgery + 4 years vascular surgery compared with longer general surgery training periods. CONCLUSION: These findings may help vascular surgery program directors devise strategies to attract future trainees. The importance of mentorship to general surgery junior residents and medical students in choosing vascular surgery cannot be overestimated. Endovascular capabilities of vascular surgeons have an increasingly positive role in career choice by GS-CRs and VSRs, but these residents express increasing concerns about potential loss of patients to other specialists. Lifestyle concerns are the most important reasons why medical students do not choose vascular surgery as a career.     

Current status of vascular surgery : in vascular medicine and general surgery]

BACKGROUND: The proportion of arterial and venous diseases is increasing due to shifts in population. Therapy is based on conventional vascular surgery and conservative endovascular methods. MATERIAL AND METHODS: Based on data from the Federal German Statistics Office and the Federal Chamber of Physicians, information was gathered on primary vascular diseases, active special vascular groups, surgical qualifications, and surgical clinics. Additionally, the status of vascular surgery at university clinics and non-university clinics with more than 900 beds was assessed. RESULTS: In 2004, 413,763 patients with primary vascular disease were treated in 1,846 German general hospitals. More than 70% of these patients were handled in vascular surgical or general surgical clinics, and operations were performed in 50% of cases. There exist independent vascular surgical departments in 213 hospitals. Thirty-three university clinics at 38 locations showed a total of six independent vascular surgery clinics (16%) and seven partially independent sections (18%). Vascular surgery is done within cardiac surgical departments in ten clinics and in general surgery department in 15 clinics. In contrast, there are independent vascular surgical departments in 39% and 53% of non-university clinics with more than 900 and 600-899 beds respectively. CONCLUSIONS: Vascular surgery has been established in hospitals as an independent speciality. This development must continue in general surgical and university clinics.     

Demand on primary health care after day surgery.

We have audited the frequency and nature of demands made on general practitioners, and the rate of surgical and anaesthetic complications within the first 7 days after day surgery. Semi-structured questionnaires were posted to the general practitioners of patients who attended the hospital''s day care ward for a surgical procedure over a 6 month period. In all, 1798 questionnaires were sent, of which 1533 (85.3%) were returned. A total of 247 (16.7%) patients consulted their general practitioners after day surgery, the principal reason being pain (113 patients). Patients who underwent incisional intermediate surgery had the highest rate (31.5%) of general practitioner consultations. This audit has quantified the workload which day surgery places upon general practitioners. It also demonstrates the importance of categorising the various procedures performed on a day case basis when examining patient outcome. Patients who underwent non-incisional minor surgery consulted their general practitioner less often than those who underwent incisional minor surgery, who in turn consulted their practitioner less often than those who underwent incisional intermediate surgery. It seems likely that an increase in workload for general practitioners is inevitable if more complex procedures are performed on a day case basis.     

Surgical trainees' attitudes to specialization in breast surgery

Background: Subspecialization in general surgery is being encouraged by various surgical societies. The aim of this study was to view attitudes of Royal Australasian College of Surgeons (RACS) trainees to subspecialization in surgery, in particular, breast ­surgery. Methods: A postal questionnaire survey of registered RACS basic and advanced surgical trainees was conducted in February 2002. Trainees were asked to nominate their preferred specialty and to indicate the level of support and interest for subspecialty training in breast surgery. Trainees indicating breast surgery as their preferred career choice were then asked to nominate their reasons for choosing breast surgery, preferred options for cross‐specialty training and for vocation specifications such as a continuing ‘on‐call’ responsibility. Results: Trainees returned 291 of 1049 (28%) completed questionnaires. One hundred and sixty‐nine trainees felt that the concept of breast subspecialization in general surgery was reasonable (58%). For all respondents, the most popular specialty choices were plastic surgery (15.8%), orthopaedics (15.5%) and general surgery (15.4%). Breast surgery was chosen by 14 of 291 (4.8%) respondents as their first specialty preference and a further 25 respondents as their second specialty preference. Of 189 trainees who did not choose breast surgery as their preferred specialty, 45% stated repetitive stress, escalating litigation or demanding patients as deterrent factors. Only 36% of trainees interested in breast surgery were interested in undertaking after hours ‘on‐call’ work as a consultant, although 36 of 39 (92%) were interested in other forms of general or subspecialty elective surgical operating (i.e., endocrine surgery, surgical oncology) after completion of their training. According to trainees with an interest in breast surgery, the two most important aspects requiring inclusion in the proposed provisional training program were breast reconstruction (38%) and breast screen assessment (34%). Conclusion: Breast surgery is an unpopular subspecialty for RACS trainees. Breast surgery is likely to experience increasing ­problems with recruitment unless the skill base is reviewed and revised in line with the aspirations and needs of today's trainees.     

Parathyroid surgery in Scandinavia

A review of the organization and practice of parathyroid surgery in Scandinavia indicated that it was undertaken in about half of the surgical clinics. About half of these clinics treated only primary hyperparathyroidism (HPT), and in the great majority all parathyroid operations were done by one or two surgeons. The results of surgical treatment were compared in two large Scandinavian series of primary HPT, one based on a general survey of parathyroid surgery in 1975, and the other on results obtained during 1971-1980 in centres specializing in endocrine surgery (Bergen, Stockholm, Uppsala). In the latter series 90% of the patients were normocalcaemic at follow-up averaging 4.4 years after parathyroid surgery whereas in the general survey the rate of normocalcaemia was 76%. At hospitals performing less than ten parathyroid operations per year it was only 70% and there was high incidence of persistent HPT (15%) and presumed permanent hypoparathyroidism (14%). The findings strongly advocate special training and interest in parathyroid surgery in order to ensure success.     

General surgery resident experience with anorectal surgery

BackgroundPrevious studies have suggested that general surgery residents graduate with suboptimal anorectal experience. However, competence in anorectal procedures is an important part of general surgery training.MethodsACGME general surgery resident case logs from 1999 to 2017 were reviewed. Mean number of anorectal procedures were evaluated, comparing Period 1 (1999–2008) and Period 2 (2009–2017).ResultsBetween 1999 and 2017, the mean number of all anorectal procedures performed by each general surgery resident has increased from 25.9 to 32.4 (by 25%). Between Period 1 and 2, mean numbers of total anorectal procedures, abscess drainage, fistula repair, hemorrhoidectomy, prolapse repair, other anorectal procedures all increased (p ≤ 0.01). Mean numbers of sphincterotomy/sphincteroplasty and other procedures for fecal incontinence significantly decreased (p ≤ 0.01).ConclusionsGeneral surgery residents have gained more experience in some anorectal procedures over time. The required number of procedures to establish competence is not well defined and should be formally evaluated.     

Voluntary changes in surgery career paths: a survey of the program directors in surgery

BACKGROUND: This article attempts to quantify the current scope of attrition, identify the reasons why categorical residents are leaving general surgery residency programs voluntarily, and correlate the program directors' and residents' perspectives. STUDY DESIGN: A questionnaire asked the Program Directors of general surgery residency programs how many categorical residents left voluntarily in the 2000-2001 academic year, their postgraduate (PGY) levels, why they left, and where they went. Another questionnaire asked the residents why they entered surgery and why they left. The surveys' responses were compared. RESULTS: A total of 206 programs (81%) responded. One hundred ten programs (53%) reported voluntarily attrition of 167 categorical residents (mean: 0.8 residents per program for all responders and 1.5 residents per program for programs that reported attrition). Seventy-three programs (66%) lost one resident; 23 programs (21%), 2 residents; 9 programs (8%), 3 residents; 4 programs (4%), 4 residents; and 1 program (<1%), 5 residents. Eighty-five PGY-1 residents (51%), 42 PGY-2 residents (25%), 27 PGY-3 residents (16%), and 13 PGY-4 residents (8%) left. The most common reasons for attrition cited by the program directors were personal and work hours/lifestyle in 40% and 35%, respectively. One hundred five residents (63%) entered other fields of medicine; 40 residents transferred to other general surgery programs. Net voluntary attrition, defined as the number of residents who left general surgery voluntarily (127) divided by the resident population at risk, was 3%, indicating that 97% of the residents at risk in the responding programs remained in general surgery. CONCLUSIONS: Most surgery programs that responded were affected by attrition in 2000-2001, with approximately one-third losing more than one resident. Attrition tends to occur early in training. Most residents enter other specialties, primarily for quality-of-life reasons. But many stay in general surgery.     

Laparoscopic surgery using spinal anesthesia.

BACKGROUND: Laparoscopic abdominal surgery is conventionally done under general anesthesia. Spinal anesthesia is usually preferred in patients where general anesthesia is contraindicated. We present our experience using spinal anesthesia as the first choice for laparoscopic surgery for over 11 years with the contention that it is a good alterative to anesthesia. METHODS: Spinal anesthesia was used in 4645 patients over the last 11 years. Laparoscopic cholecystectomy was performed in 2992, and the remaining patients underwent other laparoscopic surgeries. There was no modification in the technique, and the intraabdominal pressure was kept at 8mm Hg to 10mm Hg. Sedation was given if required, and conversion to general anesthesia was done in patients not responding to sedation or with failure of spinal anesthesia. Results were compared with those of 421 patients undergoing laparoscopic surgery while under general anesthesia. RESULTS: Twenty-four (0.01%) patients required conversion to general anesthesia. Hypotension requiring support was recorded in 846 (18.21%) patients, and 571(12.29%) experienced neck or shoulder pain, or both. Postoperatively, 2.09% (97) of patients had vomiting compared to 29.22% (123 patients) of patients who were administered general anesthesia. Injectable diclofenac was required in 35.59% (1672) for abdominal pain within 2 hours postoperatively, and oral analgesic was required in 2936 (63.21%) patients within the first 24 hours. However, 90.02% of patients operated on while under general anesthesia required injectable analgesics in the immediate postoperative period. Postural headache persisting for an average of 2.6 days was seen in 255 (5.4%) patients postoperatively. Average time to discharge was 2.3 days. Karnofsky Performance Status Scale showed a 98.6% satisfaction level in patients. CONCLUSIONS: Laparoscopic surgery done with the patient under spinal anesthesia has several advantages over laparoscopic surgery done with the patient under general anesthesia.     

The increasing workload of general surgery

BACKGROUND: With the aging of the baby boomers, individuals aged 65 years and older make up the fastest-growing segment of the US population. This aging of the population will lead to new challenges for the US health care system because older individuals are the largest consumers of health care. HYPOTHESIS: The general surgery workload will increase dramatically by 2020 as a result of the aging population. DATA SOURCES: The National Hospital Discharge Survey, National Survey of Ambulatory Surgery, US Census Bureau, and Centers for Medicare and Medicaid Services. SETTING: A nationally representative random sample of inpatient and outpatient general surgical operations performed in 1996 in the United States. METHODS: Age- and procedure-specific rates of general surgery were obtained from the National Hospital Discharge Survey and National Survey of Ambulatory Surgery. Population projections were derived from the census bureau. We used relative-value units as a proxy for surgical work. By linking these 3 data sources, we predicted the future general surgery workload by analyzing the rates of surgery and modeling both the aging and expansion of the population. RESULTS: General surgery operations (n = 63) were classified into 5 procedure categories. Whereas the population will grow by 18% between 2000 and 2020, the workload of general surgeons will increase by 31.5%. The amount of growth (19.9%-40.3%) varies among different categories of operations. CONCLUSIONS: To our knowledge, this is one of the only studies to analyze the future workload of general surgery. We project a dramatic increase in workload in the next 20 years, largely as a result of the aging US population. Our baseline assumptions are relatively conservative, so this forecast may be an underestimation. Hence, the challenge for general surgeons is to develop strategies to address this problem while maintaining quality of care for our patients.     

Critical care education in general surgery residencies

Surgical critical care (SCC) was recently identified as an essential component of general surgery by the American Board of Surgery (ABS). Previous studies have found limited attention to critical care education in general surgery programs. This survey was developed to determine the changes in critical care education, following the emphasis by the ABS. The survey determined the format for SCC education, the time and resources committed, and the views of the program directors toward SCC. Program directors of all 296 approved general surgery residencies were surveyed, with a 79% response. Most program directors (91%) agree that SCC is an essential component of general surgery, and 72% believe a separate intensive care unit (ICU) rotation should be used in SCC education. Education in SCC was provided by a separate ICU service in 110 (47%) of the programs. The remaining 53% used care of patients in the ICU during traditional services as their educational experience. The average ICU rotation for surgery residents was 9 weeks and usually occurred in the second year of training. In 97% of the 110 programs with an ICU service, lectures and conferences were conducted regularly. Seventeen programs sponsored critical care fellowships, and 25 additional programs were considering them. Ninety percent of surgical ICU services had faculty that consisted exclusively of surgeons or surgeons and other specialists. Only 53% of surgeons attending on an ICU service had a reduction in their other responsibilities. Despite overwhelming agreement that critical care is an essential component of general surgery, less than half of the training programs have an ICU service to coordinate resident education in SCC. If surgeons are to continue to provide total care to their patients, there needs to be increased commitment to SCC education.     

Threats to rural surgery

BACKGROUND: Rural surgery is a subject that often is discussed but little has been done to address the problems of rural surgery. With a decreased interest in broad-based general surgery, an aging population (especially in rural America), an aging population of general surgeons who are retiring early, surgical care in rural North America is approaching a crisis. METHODS: An internet search was performed to analyze the problems in rural surgery. Also, the experience of a 90-bed rural hospital in south central Kentucky was analyzed. RESULTS: Approximately 17% to 25% of the population in America (55 million) live in a rural environment, depending on the way rural is defined. Rural general surgeons may become an endangered species because of multiple factors, including: lack of broad-based training, increased specialization, lifestyle issues, decreased interest in surgery, increased technology, aging rural surgeons, increased workload for the general surgeon, decreased reimbursement, increased expenses, increased expectations of the general public, and increased malpractice costs. Solutions include programs dedicated to training rural surgeons, networking with university tertiary care hospitals, equal pay for work performed regardless of the location, regionalization of rural surgery centers with multiple surgeons so the lifestyle issues can be addressed. CONCLUSIONS: There is an increasing need for broad-based general surgeons in rural America. Training programs need to address the problem by offering dedicated training programs that should include primary training in general surgery and fellowships for special needs. A new specialty in rural general surgery needs to be created.     

An evaluation of emergency general surgery transfers and a call for standardization of practices

BackgroundThere is an increasing trend toward regionalization of emergency general surgery, which burdens patients. The absence of a standardized, emergency general surgery transfer algorithm creates the potential for unnecessary transfers. The aim of this study was to evaluate clinical reasoning prompting emergency general surgery transfers and to initiate a discussion for optimal emergency general surgery use.MethodsConsecutive emergency general surgery transfers (December 2018 to May 2019) to 2 tertiary centers were prospectively enrolled in an institutional review board–approved protocol. Clinical reasoning prompting transfer was obtained prospectively from the accepting/consulting surgeon. Patient outcomes were used to create an algorithm for emergency general surgery transfer.ResultsTwo hundred emergency general surgery transfers (49% admissions, 51% consults) occurred with a median age of 59 (18 to 100) and body mass index of 30 (15 to 75). Insurance status was 25% private, 45% Medicare, 21% Medicaid, and 9% uninsured. Weekend transfers (Friday to Sunday) occurred in 45%, and 57% occurred overnight (6:00 pm to 6:00 am). Surgeon-to-surgeon communication occurred with 22% of admissions. Pretransfer notification occurred with 10% of consults. Common transfer reasons included no surgical coverage (20%), surgeon discomfort (24%), or hospital limitations (36%). A minority (36%) underwent surgery within 24 hours; 54% did not require surgery during the admission. Median length of stay was 6 (1 to 44) days.ConclusionConditions prompting emergency general surgery transfers are heterogeneous in this rural state review. There remains an unmet need to standardize emergency general surgery transfer criteria, incorporating patient and hospital factors and surgeon availability. Well-defined requirements for communication with the accepting surgeon may prevent unnecessary transfers and maximize resource allocation.     

Clopidogrel and bleeding after general surgery procedures

Although many studies in the cardiothoracic literature exist about the relationship between clopidogrel and postoperative bleeding, there is scarce data in the general surgery literature. We assessed whether there are increased bleeding complications, morbidity, mortality, and resource utilization in patients who are on clopidogrel (Plavix) within 1 week before undergoing a general surgery procedure. Fifty consecutive patient charts were retrospectively reviewed after identifying patients who had pharmacy orders for clopidogrel and who underwent a general surgery procedure between 2003 and 2007. Patients who took clopidogrel within 6 days before surgery (group I, n = 28) were compared with patients who stopped clopidogrel for 7 days or more (group II, n = 22). A larger percentage of patients who took their last dose of clopidogrel within 1 week of surgery (21.4% vs 9.5%) had significant bleeding after surgery requiring blood transfusion. However, there were no significant differences between the groups in operative or postoperative blood transfusions (P = 0.12, 0.53), decreases in hematocrit (P = 0.21), hospital stay (P = 0.09), intensive care unit stay (P = 0.41), late complications (P = 0.45), or mortality (P = 0.42). Although our cohort is limited in size, these results suggest that in the case of a nonelective general surgery procedure where outcomes depend on timely surgery, clopidogrel taken within 6 days before surgery should not be a reason to delay surgery. However, careful attention must be paid to meticulous hemostasis, and platelets must be readily available for transfusion in the operating room.     

Retirement age and the work force in general surgery.

OBJECTIVE: This study examines the age of retirement of general surgery Fellows of the American College of Surgeons from 1984 through 1995 and analyzes the potential effect on the work force in general surgery of age of retirement. SUMMARY BACKGROUND DATA: Data from the Fellowship files of the American College of Surgeons, the American Board of Medical Specialties, and the American Medical Association disclosed that the number of practicing general surgeons in the United States in 1994 was between 17,289 and 23,502, or approximately 7 general surgeons per 100,000 population in the United States. METHODS: The Fellowship files of the American College of Surgeons from 1984 through 1995 were searched for general surgeons who had written to ask for retirement status or who had died before retirement. Calculations were made of the effect of years in practice on the total general surgeon work force. All living retirees from 1984 to 1985 and 1994 to 1995 were questioned to learn the factors leading to a decision to retire. RESULTS: The average age of retirement for general surgeon Fellows has risen from 60.45 in 1984 to 62.97 in 1995. Because of increasing diversion of general surgery graduates into surgical specialties, total practice years are declining despite increasing length of practice time. The principal factors for retirement decisions in 1984 and 1985 were disability (26%), leisure time (20%), and unfavorable changes in surgery (29%). In 1994 and 1995, disability was a major factor in 14% of decisions, leisure time in 20%, and unfavorable changes in surgery in 56%. CONCLUSIONS: Fewer general surgeons enter the work force each year. Thus, despite working longer, the total number of years practiced by each cohort of new general surgeons has decreased.     

A survey of Canadian general surgery residents' interest in international surgery

Objective

This survey of Canadian general surgery residents was designed to determine their interest level, past experiences and awareness of opportunities in the field of international surgery.

Methods

A web-based national survey in both French and English was sent to all Canadian general surgery residents. This survey comprised 24 questions regarding demographics, education, previous international experience, interest level and perceived opportunities in international surgery.

Results

A 27% response rate revealed a high level of interest in international surgery among Canadian general surgery residents but a low level of awareness of the opportunities and relevant organizations.

Conclusion

Further initiatives are needed to increase international surgery awareness and opportunities among general surgery residents.     

The diminishing experience in pediatric surgery for general surgery residents in the United States

PurposeThe Accreditation Council for Graduate Medical Education (ACGME) regulates the general surgery residency curriculum. Case volume remains a priority as recent concerns surrounding a lack of proficiency for certain surgical cases have circulated. We hypothesize that there is a significant decrease in pediatric surgery case numbers during general surgery residency despite residents meeting the minimum case requirements.MethodsWe reviewed publicly available ACGME case reports for general surgery residency from 1999 to 2018. Cases are classified as Surgeon Chief or Surgeon Junior. Analyzed data included case classifications, number of residents, and number of residency programs. Simple linear regression analysis was performed.ResultsWe identified a significant decrease in total number of logged pediatric surgery cases over the past 20 years (p<0.001). Nearly 60% of cases were logged under a single category – inguinal/umbilical hernia. From the past five years, pyloric stenosis was the only other category with an average of greater than two cases logged (range 2.1–2.8).ConclusionWe identified a significant decrease in total pediatric surgery case numbers during general surgery residency from 1999 to 2018. Though meeting set requirements, overall case variety was limited. With minimal number of cases required by the ACGME, graduating general surgery residents may lack proficiency in simple pediatric surgery cases.     

Getting residents in the game: an evaluation of general surgery residents' participation in pediatric laparoscopic surgery

Purpose

In a large children’s hospital, the authors evaluated general surgery residents’ experience with pediatric laparoscopic procedures and the impact of their participation on patient outcome.

Methods

The records of all children who underwent laparoscopic appendectomy, splenectomy, fundoplication, or pyloromyotomy were reviewed. The level of participation by general surgery residents in each of these operations was determined. Outcome was assessed for these procedures in terms of intraoperative and postoperative complications.

Results

A resident was the operating surgeon in 164 of 174 laparoscopic appendectomies (94%), 37 of 38 laparoscopic splenectomies (97%), 78 of 104 laparoscopic fundoplications (75%), and 72 of 97 laparoscopic pyloromyotomies (74%). Adverse outcomes in the cases in which a resident was surgeon were limited to 4 postappendectomy infectious complications, 3 cases of recurrent reflux after fundoplication, and one incomplete myotomy and one mucosal injury after laparoscopic pyloromyotomy.

Conclusions

The authors have shown that well-supervised general surgery residents can perform common, pediatric laparoscopic operations with excellent results. Although it is essential for established pediatric surgeons and fellows in pediatric surgery to acquire expertise in minimally invasive surgery, once they have confidence in their own skills they may safely permit qualified general surgery residents to perform laparoscopic procedures in children.