ORIGINAL ARTICLE

An acute care surgery fellowship benefits a general surgical residency Kelly A. Dinan, DO, James W. Davis, MD, Mary M. Wolfe, MD, Lawrence P. Sue, MD, and Kathleen M. Cagle, RN, MSN, Fresno, California

There has been a trend toward subspecialization among general surgery graduates, and many subspecialists are reticent to participate in trauma care. This has resulted in a gap in the provision of emergency surgical care. The Acute Care Surgery (ACS) fellowship, incorporating trauma, critical care, and emergency general surgery, was developed to address this need. One of the most important aspects in establishing these ACS fellowships is that they do not detract from the existing general surgery residents’ experience. METHODS: The operative case logs for residents and fellows were compared for the number of resident cases during the 3 years before the ACS fellowship and during the 3 years after the fellowship was established. Surveys were distributed to the general surgery residents addressing the impact of the fellows from the resident’s perspective at the end of the 2011 to 2012 academic year. RESULTS: There was no significant change in the number of total cases; total chief resident cases; and trauma, thoracic, or vascular procedures done per graduate. A decrease in the number of liver cases performed by the residents was noted but includes the increase in resident complement as well as the fellowship. ACS fellow cases increased from 172 cases in the first year to 221 cases in the second year and 295 in the third year. The survey showed that the residents had a very positive response to having the fellow as a teacher and did not feel like their operative experience was compromised with the addition of the ACS fellowship. CONCLUSION: The ACS fellow did not compromise general surgery resident experience and was regarded as an asset to the resident’s education. An ACS fellowship can be beneficial to residents and fellows. (J Trauma Acute Care Surg. 2014;77: 209Y212. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Care management study, level IV. KEY WORDS: Acute Care Surgery fellowship; resident experience. BACKGROUND:

B

efore 2004, there had been a decrease in applicants to general surgery residency programs. There has also been a trend toward increasing subspecialization among general surgery residency graduates. Coupled with an overall decrease in medical school applicants and the ‘‘graying’’ of the current general surgery workforce, a crisis in general surgery and specifically trauma surgery has developed.1,2 Many subspecialists are reticent to participate in trauma care.2 This has resulted in a gap in the provision of emergency surgical care. To address this issue, the American Association for the Surgery of Trauma (AAST) developed a training model, the Acute Care Surgery (ACS) fellowship.3 The fellowship, a 2-year training model that incorporates trauma, critical care, and emergency general surgery, was developed to provide the expertise to fill the growing gap in surgeons able to care for the emergency surgical patient.4Y7 In 2008, the ACS training curriculum was established and accreditation of programs by the AAST began. The initial seven accredited fellowships were established in busy Level I trauma centers with a preexisting accredited Surgical Critical Care fellowship.8 By 2013, the number of fellowships had more than doubled, with 16

Submitted: February 13, 2014, Revised: March 24, 2014, Accepted: April 1, 2014. From the Med. Ed. Program, UCSF Fresno, Fresno, California. Address for reprints: James W. Davis, MD, Med. Ed. Program, UCSF Fresno, Fresno, CA; email: [email protected] DOI: 10.1097/TA.0000000000000293

accredited ACS fellowships.9 The curriculum, while it emphasizes the acquisition of emergency surgical skills, recognizes that adequate training may not be attainable in the emergency setting. As such, there are elective rotations, specifically vascular, cardiothoracic, and hepatobiliary/transplant, that seek to teach skills in an elective setting that will be translatable to emergency situations. These are specialties with case types that have typically seen a decrease in the overall experience for graduating general surgery residents as well. With increased interest in advanced fellowship training documented in the literature,8 one of the most important aspects in establishing these ACS fellowships is the assurance that they will not detract from the existing general surgery residents’ experience.4,8 Multiple studies have shown that major case numbers performed by residents have not significantly decreased, despite the 80-hour work week restrictions and implementation of night float call.10Y13 Chief residents are still exceeding the required number of defined category cases. However, there have been decreases in operative trauma, thoracic, liver, and vascular cases documented.11,14,15 These case categories are likely to be the ones where the impact of an ACS fellowship would be of greatest concern for a general surgery training program. We hypothesized that incorporating an ACS fellowship in a high-volume general surgical residency training program would not adversely affect the resident’s operative cases, in particular that the graduating resident’s experience for operative trauma, vascular, liver, and thoracic procedures would not

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be significantly diminished. Further, we sought to discover whether the ACS fellowship could enhance the general surgery residency as additional resources and teachers1 as well as to determine the general surgery residents’ attitudes regarding the ACS fellowship.

MATERIALS AND METHODS This retrospective study took place at UCSF-Fresno, a 625-bed American College of SurgeonsYverified Level I trauma center with an AAST-accredited ACS fellowship. The ACS fellowship was created at UCSF-Fresno in 2010, with one fellow selected per year. There continues to be an Accreditation Council for Graduate Medical Education (ACGME)Yapproved 1-year Surgical Critical Care fellowship with one fellow per year as well. Since 2011, there have been three fellows who could, potentially, compete for major cases with the general surgical residents in the training program. The ACGME operative case logs were reviewed to determine the number of operative cases upon residency completion. This information is of public domain and was made available from the ACGME Web site. The defined category report of the cases of the graduating residents was recorded by year for the 3 years before establishing the fellowship (2007Y2008, 2008Y2009, and 2009Y2010), the initial year of the fellowship (2010Y2011) with one ACS fellow, and then the following two academic years (2011Y2012 and 2012Y2013) when there were two ACS fellows. The operative cases of the fellows were identified and recorded using the AAST ACS operative log system. All case types were reviewed and categorized according to the AAST ACS curriculum of ‘‘essential’’ and ‘‘desirable’’ cases. Specific attention was then given to trauma, thoracic, liver, and vascular categories. The general surgery residents’ attitudes about the ACS fellowship were assessed using a survey given during the academic year 2011 to 2012, when the full complement of fellows had been attained. The survey tool was composed of six questions. Response options to these questions were based on a 5-part Likert-type scale (1, strongly agree; 5, strongly disagree). Other information collected included the demographics of the residents, their year in residency, age, and sex. Participation in the survey was voluntary and anonymous (Table 1).

TABLE 1. Resident Survey Questions 1 2. 3. 4. 5. 6.

ACS fellows are effective as teachers. The ACS fellow did not limit or compete with my chance or ability to perform procedures. The distinction between my clinical responsibilities and the fellow’s was clear. Having an ACS fellow is an asset to my surgical training. The ACS fellow did not detract from my OR experience. The ACS fellow did not take away from my learning experience in the management of the surgical and trauma patient.

Resident survey questions 1 through 6 concerning the ACS fellows on a 1 (strongly agree) to 5 (strongly disagree) Likert scale. OR, operating room.

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Statistical analysis was performed using one-way analysis of variance, with significance attributed to a p value of less than 0.05. The 3 years before the establishment of the ACS fellowship was used as the baseline (pre-ACS), and this was compared with each of the 3 years of the ACS fellowship (ACS 1, ACS 2, and ACS 3). A two-tailed t test was then used to further delineate statistically significant differences in the number of specific cases by year. In addition, Pearson correlation coefficient was used to determine correlation between individual survey questions (IBM SPSS statistics, version 20, IBM Corporation, Chicago, IL). This study was approved by the institutional review board of the University of California San Francisco, Fresno, and Community Regional Medical Center and qualified for a waiver of informed consent.

RESULTS The study period extended from July 2007 through June 2013. During the prefellowship period, there were 18, 19, and 20 total residents, with 3 graduates per year during the first 2 years and 4 graduates in the final prefellowship year. There were two ACGME-approved resident complement increases just before (2006) and during the study period (2009). Because of the expansion, there were 24 residents in 2012 to 2013, with a total of 4 chief residents. The case numbers for the graduating surgical residents, total cases, total chief cases, trauma, thoracic, vascular, and liver, are shown in Table 2. There was no significant change in the mean number of total cases; chief resident cases; and vascular, trauma, or thoracic cases. There was a significant decrease in the number of liver procedures done per graduate, mostly because of the changes in the ACS 3 year. When analyzing by year, there were no significant changes in the number of cases of any type during the first year of the ACS fellowship and during the second year of the ACS fellowship and there was a significant increase in vascular cases. The thirdyear comparison demonstrated the decrease in the number of liver cases. This year reflects not only the resident complement increase but also a change in rotation assignments that impacted the 2012 to 2013 graduating chiefs. The rotation change left these residents without a formal hepatobiliary rotation. All graduates that year were still able to obtain more than the minimum required ACGME numbers for hepatic surgical cases. There was a trend toward a decreasing number of trauma cases (95Y67) that did not reach statistical significance. However, this change includes the increase in resident complement as well as the establishment of the fellowship. In addition, the mean number of trauma cases done (67) was significantly greater than either the ACGME minimum number (10) or the total national resident mean of trauma cases (29). Of note, the number of trauma cases done per graduate has remained higher than the 90th percentile for all general surgery residency programs.15 The operative experience of the ACS fellows was robust and increased during the study period. The ACS fellows performed a mean of 172 cases in the first year of the fellowship, 221 cases in the second year of the fellowship, and 295 in the third year of the fellowship (Table 3). The ACS * 2014 Lippincott Williams & Wilkins

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TABLE 2. Resident Cases Before and With the ACS Fellowship Total residents Total major cases Chief resident Trauma Thoracic Vascular Liver

Pre-ACS 2007Y2010

ACS Year 1 2010Y2011

ACS Year 2 2011Y2012

ACS Year 3 2012Y2013

p

57 1,365 (1,372) 1,073Y1,619 312 (317) 240Y397 95 (80) 40Y180 36 (30) 22Y61 135 (134) 72Y206 13 (13) 6Y26

21 1,341 (1,296) 1,279Y1,494 300 (292) 276Y342 87 (89) 61Y108 28 (26) 23Y36 176 (168) 157Y211 11 (11) 5Y16

23 1,301 (1,208) 1,194Y1,422 313 (302) (249Y400) 64 (66) 37Y68 26 (24) 16Y40 195 (202) 146Y232 11 (10) 5Y16

24 1,277 (1,301) 1,195Y1,367 278 (280) (246Y308) 67 (73) 46Y78 25 (20) 17Y46 196 (184) (154Y265) 6 (5) 5Y9

N/A 0.57 0.63 0.39 0.40 0.06 0.012

Resident cases by defined category and total before and with the institution of the ACS fellowship. Data are expressed as mean (median) range. N/A, not applicable.

fellowship curriculum9 includes 67 specific procedure types as essential and desirable. The fellows performed almost all of these procedures. The seven procedures not performed are shown in Table 4. The survey of the surgery residents was performed at the end of the 2011 to 2012 academic year, and 17 (73%) of 23 residents participated. Results of all survey questions are shown in Figure 1. The most common responses to all the survey questions were either 1 (‘‘strongly agree’’) or 2 (‘‘somewhat agree’’), indicating an overall positive opinion of the ACS fellows as teachers and assets to the program. Survey question responses were evaluated using Pearson correlation coefficient. Responses to Question 2 correlated with the responses to Question 4 (p = 0.006), Question 5 (p = 0.03), and Question 6 (p = 0.003), demonstrating internal validity of those survey questions (Fig. 1).

DISCUSSION The ACS fellowship and curriculum were created to fill the need for expertise in emergency general surgery as well as trauma and critical care. This has been the subject of several AAST Presidential Addresses.16,17 Dr. Meredith16 noted that ACS fellows need to be trained to be ‘‘experts in managing patients who have surgical diseases in critical care, trauma and emergency general surgery.’’ There have been concerns raised that adding an ACS fellowship could detract from the quality of experience of the preexisting general surgery residency. With work-hour restrictions and the increased number of requirements for cases, some program directors have become concerned that, with the addition of fellows, the residents will not become proficient in certain cases.18 Studies have shown that the fellow supervision

of surgical procedures did not detract from the resident operative experience.18,19 Our data demonstrate that an ACS fellowship can be successfully incorporated into a high-volume surgical training program without significantly detracting from the general surgical resident’s operative experience.20 Despite increasing numbers of cases done by the fellows, the residents continued to maintain adequate numbers overall and in those specialties that have previously been an area of concern. Our survey also shows that the residents viewed the ACS fellows in a positive manner in all aspects of their training. The ACS fellows function as instructors on a daily basis on rounds and in the operating rooms. Overall, the residents value the ACS fellows as teachers and perceive them as an asset to their training. While it is crucial that the ACS fellowship does not detract from the general surgery residency, it is also important that the fellowship provide an adequate operative experience, if this curriculum is to fill the gap in emergency surgical coverage. The essential and desirable case list for the ACS curriculum was developed based on expert opinion. It contains complex emergency, urgent, and elective cases, some of which are infrequently encountered and may therefore cause interference with the experience of the general surgery residents. The current report demonstrates that the fellows did have a robust operative experience, performing almost all of the essential and desirable cases in the ACS curriculum. Further study with the developing AAST ACS case log is warranted to evaluate the appropriateness of the essential and desirable case list. TABLE 4. Procedures Not Logged of Essential and Desirable Cases Area/Procedure

TABLE 3. ACS Fellow Operative Cases ACS 1 Total fellows Mean cases Trauma Thoracic Vascular Liver

1 172 45 3 7 0

ACS 2 2 221 55 3.5 32 2.5

ACS fellow operative cases by year and defined category.

ACS 3 2 295 112 13 24 10

Airway Chest Neck

Essential Cricothyroidotomy Spine exposure

Abdomen and pelvis Extremities Other

Desirable Partial left heart bypass Parathyroidectomy Elective neck dissection Management of injuries to the female reproductive tract Hemodialysis access, permanent

Treatment of hypothermia

Procedures in essential and desirable categories not logged by the ACS fellows.

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J.W.D., and L.P.S. prepared the manuscript. J.W.D., L.P.S., and M.M.W. contributed to critical revisions.

DISCLOSURE The authors declare no conflicts of interest.

REFERENCES

Figure 1. Resident survey responses about ACS fellows in the same order as in Table 1, with the number of responses for each answer (strongly agree, agree, neutral, disagree, and strongly disagree). OR, operating room.

The findings of our investigation are consistent and demonstrate that a strong general surgery residency experience can be maintained while providing an excellent depth and breadth of experience for an ACS fellowship. The study is subject to all the limitations of a retrospective review. The case log data were gleaned from the ACGME and AAST ACS case logs. It is possible that some of the cases were not logged or were logged incorrectly. However, the residency coordinator and the program director monitor the resident case logs on a weekly basis to ensure that cases are in fact logged in a timely and correct fashion. In addition, this is a single-institution report and may not apply to all general surgery residencies and ACS fellowship programs because of variances in clinical volumes. The survey tool was not externally validated but did directly address the potential issues surgical residents may have with the ACS fellows.

CONCLUSION The ACS fellowship was designed to fill a need for expertise in treating the emergency general surgery patient.15,16 The ACS fellowship seeks to adequately train surgeons who are experts in treating these patients. This must be accomplished without interfering with the education of the general surgery residents. We have shown that an ACS fellowship can be established and can provide adequate case volumes for the fellows without negative impact on a surgical residency. In a busy academic practice, an ACS fellowship and general surgical residency can coexist with the added benefit of fellows as educators and mentors. AUTHORSHIP K.A.D., J.W.D., and L.P.S. designed this study. K.A.D. collected the data. K.A.D., J.W.D., L.P.S., and K.M.C. performed data analysis. K.A.D.,

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1. Rotondo MF, Esposito TJ, Reilly PM, Barie PS, Meredith JW, Eddy VA, Rabinovici R, Jacobs LM, Cunningham PR, Frykberg ER, et al. The position of the Eastern Association for the Surgery of Trauma on the future of trauma surgery. J Trauma. 2005;59(1):77Y79. 2. Esposito TJ, Rotondo M, Barie PS, Reilly P, Pasquale MD. Making the case for a paradigm shift in trauma surgery. J Am Coll Surg. 2006;202(4):655Y667. 3. Committee on Acute Care Surgery American Association for the Surgery of Trauma. The acute care surgery curriculum. J Trauma. 2007;62(3):553Y556. 4. Fairfax LM, Christmas AB, Green JM, Miles WS, Sing RF. Operative experience in the era of duty hour restrictions: is broad-based general surgery training coming to an end? Am Surg. 2010;76(6):578Y582. 5. Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190(2):212Y217. 6. Kelly E, Rogers SO Jr. Graduate medical education in trauma/critical care and acute care surgery: defining goals for a new workforce. Surg Clin North Am. 2012;92(4):1055Y1064. 7. Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV. Acute care surgery: now that we have built it, will they come? J Trauma Acute Care Surg. 2013;74(2):463Y468; discussion 468Y469. 8. Tisherman SA, Ivy ME, Frangos SG, Kirton OC. Acute care surgery survey: opinions of surgeons about a new training paradigm. Arch Surg. 2011;146(1):101Y106. 9. American Association for the Surgery of Trauma. Acute Care Surgery Web page. Available at: http://www.aast.org/AcuteCareSurgery.aspx. Accessed August 15, 2013. 10. McElearney ST, Saalwachter AR, Hedrick TL, Pruett TL, Sanfey HA, Sawyer RG. Effect of the 80-hour work week on cases performed by general surgery residents. Am Surg. 2005;71(7):552Y555; discussion 555Y556. 11. Christmas AB, Brintzenhoff RA, Sing RF, Schmelzer TM, Bolton SD, Miles WS, Thomason MH. Resident work hour restrictions impact chief resident operative experience. Am Surg. 2009;75(11):1065Y1068. 12. Bruce PJ, Helmer SD, Osland JS, Ammar AD. Operative volume in the new era: a comparison of resident operative volume before and after implementation of 80-hour work week restrictions. J Surg Educ. 2010;67(6): 412Y416. 13. Kelly RJ Jr, Senkowski CK. Effect of the night float system on operative case volume for senior surgical residents. J Surg Educ. 2009;66(6): 314Y318. 14. Helling TS, Khandelwal A. The challenges of resident training in complex hepatic, pancreatic, and biliary procedures. J Gastrointest Surg. 2008;12(1): 153Y158. 15. American Council for Graduate Medical Education. Resident case log system. Available at: http://www.acgme.org/acgmeweb/tabid/161/DataCollectionSystems/ ResidentCaseLogSystem.aspx. Accessed August 15, 2013. 16. Meredith JW. How to boil a frog: the American Association for the Surgery of Trauma in changing times. J Trauma Acute Care Surg. 2013;74(1):1Y7. 17. Peitzman AB. ‘‘Of courage undaunted’’: 2010 AAST Presidential Address. J Trauma. 2011;70(1):1Y10. 18. Hallowell PT, Dahman MI, Stokes JB, LaPar DJ, Schirmer BD. Minimally invasive surgery fellowship does not adversely affect general surgery resident case volume: a decade of experience. Am J Surg. 2013;205(3): 307Y311; discussion 311. 19. Diaz JJ Jr, Miller RS, May AK, Morris JA Jr. Acute care surgery: a functioning program and fellowship training. Surgery. 2007;141(3): 310Y316. 20. Endorf FW, Jurkovich GJ. Acute care surgery: a proposed training model for a new specialty within general surgery. J Surg Educ. 2007;64(5): 294Y299.

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An acute care surgery fellowship benefits a general surgical residency.

There has been a trend toward subspecialization among general surgery graduates, and many subspecialists are reticent to participate in trauma care. T...
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