Research
Original Investigation
Bariatric Surgery and the Changing Current Scope of General Surgery Practice Implications for General Surgery Residency Training Rouzbeh Mostaedi, MD; Mohamed R. Ali, MD; Jonathan L. Pierce, MD; Lynette A. Scherer, MD; Joseph M. Galante, MD
IMPORTANCE The scope of general surgery practice has evolved tremendously in the last 20 years. However, clinical experience in general surgery residency training has undergone relatively little change. OBJECTIVE To evaluate the current scope of academic general surgery and its implications on surgical residency. DESIGN, SETTING, AND PARTICIPANTS The University HealthSystem Consortium and Association of American Medical Colleges established the Faculty Practice Solution Center (FPSC) to characterize physician productivity. The FPSC is a benchmarking tool for academic medical centers created from revenue data collected from more than 90 000 physicians who practice at 95 institutions across the United States. MAIN OUTCOMES AND MEASURES The FPSC database was queried to evaluate the annual mean procedure frequency per surgeon (PFS) in each calendar year from 2006 through 2011. The associated work relative value units (wRVUs) were also examined to measure physician effort and skill. RESULTS During the 6-year period, 146 distinct Current Procedural Terminology codes were among the top 100 procedures, and 16 of these procedures ranked in the top 10 procedures in at least 1 year. The top 10 procedures accounted for more than half (range, 52.5%-57.2%) of the total 100 PFS evaluated for each year. Laparoscopic Roux-en-Y gastric bypass was consistently among the top 10 procedures in each year (PFS, 18.2-24.6). The other most frequently performed procedures included laparoscopic cholecystectomy (PFS, 30.3-43.5), upper gastrointestinal tract endoscopy (PFS, 26.5-34.3), mastectomy (PFS, 16.5-35.0), inguinal hernia repair (PFS, 15.5-22.1), and abdominal wall hernia repair (PFS, 21.6-26.1). In all years, laparoscopic Roux-en-Y gastric bypass generated the highest number of wRVUs (wRVUs, 491.0-618.2), and laparoscopic cholecystectomy was regularly the next highest (wRVUs, 335.8-498.7). CONCLUSIONS AND RELEVANCE A significant proportion of academic general surgery is composed of bariatric surgery, yet surgical training does not sufficiently emphasize the necessary exposure to technical expertise and clinical management of the patient undergoing bariatric surgery. As the scope of general surgery practice continues to evolve, general surgery residency training will need to better integrate the exposure to bariatric surgery. Author Affiliations: Department of Surgery, University of California, Davis, Sacramento (Mostaedi, Ali, Pierce, Galante); Department of Trauma, Mercy San Juan Medical Center, Carmichael, California (Scherer).
JAMA Surg. 2015;150(2):144-151. doi:10.1001/jamasurg.2014.2242 Published online December 23, 2014. 144
Corresponding Author: Joseph M. Galante, MD, Department of Surgery, University of California, Davis, 2221 Stockton Blvd, Cypress Bldg, Sacramento, CA 95817 (joseph [email protected]). (Reprinted) jamasurgery.com
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Bariatric Surgery
Original Investigation Research
T
he American Board of Surgery (ABS) defines general surgery as a “discipline that requires knowledge of and familiarity with a broad spectrum of diseases that may require surgical treatment.” 1(p5) The domain of expertise encompassed by general surgery is a heterogeneous understanding of anatomy, physiology, and technical capability of treating the surgical patient.2 Since 2004, the ABS stated that the “certified general surgeon is expected to have knowledge and skills in the management and team-based interdisciplinary care of morbidly obese patients, to include metabolic derangements, weight loss surgery and the counseling of patients and families.”1(p1)2 General surgeons must actively familiarize themselves with the conditions that face patients undergoing bariatric surgery because the patients are clinically morbidly obese. The prevalence of obesity in the United States has been increasing in the last decade, and an epidemiologic survey revealed that approximately 36% of the adult population is obese.3,4 In response to the obesity epidemic and the efficacy of surgical weight loss, the annual number of bariatric operations is more than 100 000 in the United States and more than 340 000 worldwide in 2011.5 At our own institution, we have witnessed the increasing frequency of patients undergoing bariatric surgery who are being cared by medical specialists, and this patient population will continue to have an increasing presence in the practices of primary care physicians and all specialized surgical physicians. We hypothesize that bariatric surgery comprises a substantial proportion of current academic surgical practice. We sought to describe the national trend of general surgery practice at academic medical centers in the United States and its implications for the scope of general surgery residency training.
Methods The University of California Institutional Review Board approved this study as exempt because no patient data were included in the study. Colleges established the Faculty Practice Solution Center (FPSC) to more accurately characterize physician productivity. The FPSC is a national benchmarking tool for academic medical centers created from revenue data collected from more than 90 000 physicians who practice at 95 institutions across the United States. Faculty physicians who are clinically active for more than 60% of their time within a specific specialty are included in the benchmarking process. Within the FPSC, surgery is subcategorized into general, trauma, burn, thoracic, cardiac, plastic, oncology, vascular, pediatric, and transplant surgery. Each faculty surgeon is uniquely classified into one these specialties by the academic medical centers to avoid any physician crossover into multiple specialties. Each year, approximately 250 of these surgeons are classified in the general surgery specialty. However, the FPSC database does not separately categorize minimally invasive surgery or bariatric surgery. We assume that surgeons who perform these procedures are included within the general surgery specialty. jamasurgery.com
The information from the FPSC database includes Current Procedural Terminology (CPT) codes and associated relative value units (RVUs). The CPT codes provide standardized reporting of physician services. In this study, we evaluated the reported annual mean procedure frequency per surgeon (PFS). The PFS is defined as the mean number of each CPT-coded procedure performed by a general surgeon during each year. The RVUs attached to a CPT code are indicative of the effort required to perform the service. To more specifically target the level of time, skill, training, and intensity required to provide a service, we focused on the physician work RVUs (wRVUs). For example, the wRVUs for the laparoscopic Roux-en-Y gastric bypass (RYGB) and Whipple procedures are 3.7 and 6.6 times greater than the repair of the inguinal hernia, respectively. Deidentified coding and billing information was extracted from the FPSC database for the calendar years 2006 through 2011. A filtering method was designed and is detailed in the Figure. Only data from the general surgery specialty were used, and data from the other 9 previously listed surgical specialties were excluded. The total reported CPT codes for general surgery ranged from 1965 to 2320, depending on the year. To identify commonly performed operations, the CPT codes for each year were sorted by PFS from highest to lowest. Each CPT code was individually evaluated. The evaluation and management CPT codes were excluded to focus only on procedure CPT codes. We used the ABS to only include defined procedures and exclude procedures listed “not for major credit” (n = 83). For example, minor procedures, such as tube thoracostomy placement, central catheter placement, and simple incision and drainage, were excluded from the study. Furthermore, we focused on CPT codes considered “primary” procedures and excluded procedures labeled “list separately in addition to primary procedure” (n = 23). The filtering method was applied to each CPT code until the 100 most frequently performed procedures were selected for each year from 2006 through 2011. The CPT codes were organized into 10 surgical categories based on procedure type and organ system (Table 1). For example, the hepatobiliary, pancreas, and solid-organ surgery category is consolidated into 6 generalized procedures: (1) cholecystectomy, (2) laparoscopic cholecystectomy, (3) hepatobiliary and solid-organ procedures, (4) laparoscopic hepatobiliary and solid-organ procedures, (5) pancreatic resection, Whipple type, and (6) pancreatic procedures. In addition, the CPT codes were categorized into more generalized procedures. The CPT codes for laparoscopic cholecystectomy without cholangiography (CPT code 47562) and laparoscopic cholecystectomy with cholangiography (CPT code 47563) are listed as a single general procedure—laparoscopic cholecystectomy.
Results The list of the 100 most frequently performed procedures varied from year to year. Thus, 146 unique CPT codes were identified to have been among the 100 most frequently performed procedures during the entire study period (Table 1). The (Reprinted) JAMA Surgery February 2015 Volume 150, Number 2
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Bariatric Surgery
Figure. Current Procedural Terminology (CPT) Code Filter Method for the Top 100 Most Frequently Performed Procedures All surgery Reported CPT codes
Speciality surgery Trauma Plastic Oncology Burn Vascular Thoracic Pediatric Cardiac Transplant
General surgery 1965-2320 Total CPT codes for each year from 2006 to 2011
CPT codes sorted by PFS from highest to lowest
“Procedure” CPT code?
No
Excluded CPT codes designated “evaluation and management”
No
Excluded CPT codes listed as “not for major credit” by the ABS
Yes ABS “defined” procedure?
Repeat for each CPT code until top 100 procedures reached
Yes ABS “primary” procedure?
No
Excluded CPT codes listed as “list separately in addition to primary procedure”
Yes
Accepted as a top 100 ABS “defined primary procedure” in general surgery for each year from 2006 to 2011
146 Unique CPT codes appeared in the top 100 procedures in at least one year from 2006 to 2011
ABS indicates American Board of Surgery; PFS, procedure frequency per surgeon.
nonselected codes all had a PFS less than 2, indicating that academic surgeons performed fewer than 2 of these procedures per year.
Procedure Frequency per Surgeon The PFS for the 100 CPT codes were compared, and the most frequently performed procedures from 2006 through 2011 are listed in Table 2. In all years, these 100 CPT codes represented a significant bulk of ABS-defined primary operations. Overall, 16 procedures were among the 10 most commonly performed procedures at least once from 2006 through 2011. Each year, the top 10 procedures accounted for more than half (range, 52.5%-57.2%) of the total top 100 procedures. Consistently, 6 operations ranked among the top 10 most commonly performed procedures every year (Table 2). Laparoscopic cholecystectomy (PFS, 30.3-43.5), upper gastrointestinal tract endoscopy (PFS, 26.5-34.3), laparoscopic RYGB (PFS, 18.2-24.6), partial or complete mastectomy (PFS, 16.5-35.0), inguinal hernia repair (PFS, 15.5-22.1), and abdominal wall hernia repair (PFS, 21.6-26.1) combined to represent at least 37% of the top 100 procedures performed by academic general surgeons. Individually, the mean PFS for laparoscopic cholecystectomy increased annually and peaked in 2011 (PFS, 43.5) and represented 11.1% of the top 100 procedures. Laparoscopic RYGB comprised 4.8% to 6.7% of all procedures. The 2 hernia operations represented at least 10% of academic general sur146
gery practice. Although upper gastrointestinal tract endoscopy was one of the most frequently performed procedures in all years, lower gastrointestinal tract endoscopy was also a prevalent procedure that ranked among the top 10 in 5 of the 6 years. In total, these 2 procedures accounted for 10.1% to 13.8% of the top 100 procedures. The PFS was examined for each surgical category (Table 3). The categories of hepatobiliary, pancreas, and solid-organ surgery (PFS, 53.6-66.0), hernia surgery (PFS, 53.1-70.7), and intestinal surgery (PFS, 66.8-75.5) were the only 3 surgical categories with a PFS greater than 50 in all years. These surgical categories individually represented a significant proportion (range, 14%-21%) of all procedures, and in total they constituted up to 57% of general surgery practice. Of the remaining surgical categories, foregut surgery (PFS, 46.6-57.0); head, neck, and thoracic surgery (PFS, 31.2-36.9); and breast surgery (PFS, 27.1-54.5) were commonly performed and additionally represented the breadth of general surgery. Bariatric surgery (PFS, 29.4-35.6) was common in all years and peaked in 2011 (Table 3). In addition to laparoscopic RYGB, laparoscopic adjustable gastric band surgery was among the top 10 most frequently performed procedures in 2008 (PFS, 12.4) and 2009 (PFS, 12.5). The PFS for gastric restrictive procedures precipitously decreased from 2006 to 2011 as more specific bariatric CPT codes became available. In 2010, the CPT code for laparoscopic sleeve gastrectomy was introduced, and
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Bariatric Surgery
Original Investigation Research
Table 1. CPT Codes Consolidated Into Surgical Categories CPT Code(s)
Surgical Category Bariatric Gastric restrictive procedure
43843, 43846
Laparoscopic Roux-en-Y gastric bypass
43644
Laparoscopic adjustable gastric band procedure
43770, 43774
Laparoscopic sleeve gastrectomy
43775
Breast Mastectomy, partial or complete
19120, 19125, 19160, 19180, 19301, 19303
Mastectomy, with axillary lymphadenectomy Axillary lymphadenectomy, biopsy or complete
19162, 19240, 19302, 19307 38500, 38525, 38745
Foregut Upper gastrointestinal tract endoscopy, diagnostic and therapeutic Esophagogastric procedure
43234, 43235, 43239, 43245, 43246, 43249, 43262, 43750 43820, 43830, 43840, 43999
Laparoscopic esophagogastric procedure
43279, 43280, 43281, 43282, 43289, 43659
General abdomen Intra-abdominal procedure
22558, 38747, 49000, 49002, 49020, 49999
Laparoscopic intra-abdominal procedure
49320, 49321, 49329
Hepatobiliary, pancreas, and solid organ Cholecystectomy
47600, 47605
Laparoscopic cholecystectomy
47562, 47563
Hepatobiliary and solid-organ procedure
38100, 47100, 47120, 47780
Laparoscopic hepatobiliary and solid-organ procedure
38120, 47379, 58662, 60650
Pancreatic resection, Whipple type
48150, 48153
Pancreatic procedure
48005, 48140, 48999
Hernia Repair of inguinal hernia
49505, 49507, 49520
Laparoscopic repair of inguinal hernia Repair of abdominal wall hernia
49650, 49651 49560, 49561, 49565, 49566, 49585, 49587
Laparoscopic repair of abdominal wall hernia
49652, 49653, 49654, 49655, 49659
Head, neck, and thoracic Upper and lower airway endoscopy, diagnostic or therapeutic Thyroidectomy, partial or complete
31575, 31622, 31624, 31646 60220, 60225, 60240, 60252, 60260, 60271
Parathyroidectomy
60500
Head, neck, and thoracic procedure, nonendocrine
21555, 31600, 38510, 38724
Intestinal Lower gastrointestinal tract endoscopy, diagnostic or therapeutic Small-bowel procedure
45378, 45380, 45384, 45385 44005, 44120, 44130
Laparoscopic small-bowel procedure Large-bowel procedure
44180, 44200, 44202, 44238 44140, 44143, 44145, 44150, 44160
Laparoscopic large-bowel procedure
44204, 44205, 44207
Appendectomy
44950
Laparoscopic appendectomy
44970
Enterostomy, creation or closure
44300, 44310, 44320, 44620, 44625, 44626
Repair of bowel injury, perforation or fistula Anorectal procedure
44602, 44604, 44640 46040, 46255, 46260, 46270
Skin and soft tissue Skin graft or soft tissue flap
15100, 15120, 15300, 15350, 15430, 15734
Excision of skin or soft tissue lesions
11606, 21930, 21931
Surgical wound procedures, debridement or preparation
11043, 11044, 13160, 15000, 15002, 15004
Nongeneral surgery Nongeneral surgery
33533, 36200, 47135, 50360, 50547
Abbreviation: CPT, Current Procedural Terminology.
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Table 2. Highest PFS in Academic General Surgery From 2006 to 2011 Mean PFS (% of Total Procedures) Procedure
2006
2007
2009
2010
2011
Laparoscopic cholecystectomy
30.3 (8.3)a
30.4 (8.1)a
36.0 (9.5)a
36.1 (9.5)a
40.9 (10.4)a
43.5 (11.1)a
Laparoscopic Roux-en-Y gastric bypass
24.6 (6.7)a
20.8 (5.6)a
18.2 (4.8)a
18.3 (4.8)a
19.7 (5.0)a
22.0 (5.6)a
Mastectomy, partial or complete
18.2 (5.0)a
17.3 (4.6)a
19.2 (5.1)a
19.4 (5.1)a
35.0 (9.1)a
16.5 (4.2)a
Repair of inguinal hernia
18.6 (5.1)a
15.5 (4.1)a
20.6 (5.4)a
20.7 (5.5)a
22.1 (5.7)a
17.9 (4.6)a
Repair of abdominal wall hernia
a
21.6 (5.9)
a
22.7 (6.1)
a
24.1 (6.4)
a
24.2 (6.4)
a
24.5 (6.3)
26.1 (6.7)a
Upper gastrointestinal tract endoscopy, diagnostic and therapeutic
32.1 (8.8)a
34.3 (9.2)a
29.3 (7.7)a
29.2 (7.7)a
26.5 (6.8)a
29.9 (7.7)a
Lower gastrointestinal endoscopy, diagnostic or therapeutic
11.4 (3.1)a
17.2 (4.6)a
12.4 (12.4)a
12.4 (3.3)a
14.0 (3.6)a
9.7 (2.5)
Thyroidectomy, partial or complete
9.0 (2.4)
12.3 (3.3)a
13.4 (3.5)a
13.4 (3.6)a
13.3 (3.4)a
15.6 (4.0)a
11.8 (3.2)a
13.5 (3.6)a
12.9 (3.4)a
12.9 (3.4)a
10.8 (2.8)
9.8 (2.5)
a
a
Large-bowel procedure
2008
13.0 (3.6)
12.5 (3.3)
12.0 (3.2)
11.8 (3.1)
8.9 (2.3)
8.0 (2.0)
Laparoscopic adjustable gastric band procedure
NA
5.7 (1.5)
12.4 (3.3)a
12.5 (3.3)a
8.4 (2.2)
7.3 (1.9)
Small-bowel procedure
11.9 (3.2)a
11.9 (3.2)
10.9 (2.9)
10.9 (2.9)
9.8 (2.5)
11.1 (2.9)a
Intra-abdominal procedure
Axillary lymphadenectomy, biopsy or complete
10.0 (2.7)
Laparoscopic appendectomy
9.4 (2.5)
11.7 (3.1)
11.7 (3.1)
a
9.4 (2.4)
a
16.0 (4.2)
8.2 (2.2)
7.7 (2.1)
11.2 (3.0)
11.2 (3.0)
12.1 (3.1)
10.7 (2.8)
Laparoscopic esophagogastric procedure
11.3 (3.1)
9.0 (2.4)
7.9 (2.1)
7.9 (2.1)
10.0 (2.6)
17.8 (4.5)a
Laparoscopic repair of inguinal hernia
7.3 (2.0)
7.5 (2.0)
8.1 (2.1)
8.1 (2.1)
10.8 (2.8)
15.6 (4.0)a
Abbreviations: NA, not applicable; PFS, mean procedure frequency per surgeon. a
Ranked in the top 10 procedures for the designated year from 2006 to 2011.
Table 3. Total PFS in Academic General Surgery From 2006 to 2011 Mean PFS (% of Total Procedures) Surgical Category
2006
2007
2008 32.2 (8.5)
2009 32.5 (8.6)
2010 29.4 (7.5)
2011
Bariatric
31.9 (8.8)
30.0 (8.0)
35.6 (9.1)
Breast
30.8 (8.4)
29.2 (7.8)
33.1 (8.8)
33.3 (8.8)
54.5 (13.9)
27.1 (6.9)
Foregut
53.8 (14.7)
53.8 (14.4)
49.2 (13.0)
49.2 (13.0)
46.6 (11.9)
57.0 (14.6)
General abdomen
17.9 (4.9)
17.8 (4.8)
18.3 (4.8)
18.1 (4.8)
13.6 (3.5)
13.8 (3.5)
Hepatobiliary, pancreas, and solid organ
53.6 (14.7)
56.2 (15.0)
60.7 (16.1)
60.9 (16.1)
60.8 (15.5)
66.0 (16.9)
Hernia
54.5 (14.9)
53.1 (14.2)
59.8 (15.8)
60.1 (15.9)
64.9 (16.6)
70.7 (18.1)
Head, neck, and thoracic
31.2 (8.6)
33.6 (9.0)
36.9 (9.8)
36.9 (9.7)
33.9 (8.7)
32.9 (8.4)
Intestinal
68.7 (18.8)
75.5 (20.2)
71.2 (18.8)
71.2 (18.8)
72.3 (18.5)
66.8 (17.1)
Skin and soft tissue
18.5 (5.1)
19.6 (5.3)
12.5 (3.3)
4.1 (1.1)
14.6 (3.7)
2.7 (0.7)
Nongeneral surgery
4.1 (1.1)
4.7 (1.2)
4.1 (1.1)
12.3 (3.3)
0.9 (0.2)
18.1 (4.6)
Abbreviation: PFS, mean procedure frequency per surgeon.
the frequency of laparoscopic sleeve gastrectomy (PFS, 5.8) had already begun to approach laparoscopic adjustable gastric band surgery (PFS, 7.3) in 2011.
Work Relative Value Units Each unique CPT code has an assigned wRVU that indicates the skill and effort required to perform the specific procedure. The wRVUs assigned to each of the 100 procedures with the highest PFS were evaluated (Table 4). 148
In all years, laparoscopic RYGB generated the highest wRVUs per academic surgeon. This procedure consistently accounted for more than 10% of the annual wRVUs generated of the 100 most frequently performed procedures. In 2006, the generated wRVU for laparoscopic RYGB was 618.1, which represented 14.8% of all wRVUs. After a slight decrease in the intervening years, this procedure returned to its high wRVU in 2011 (618.2, which represented 11.9% of all wRVUs). Laparoscopic cholecystectomy was consistently second highest in
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Bariatric Surgery
Original Investigation Research
Table 4. Highest Generated wRVUs in Academic General Surgery From 2006 to 2011 Mean wRVUs (% of All wRVUs) Procedure
2006
2007
2008
2009
2010
2011
Laparoscopic cholecystectomy
335.8 (8.0)a
347.9 (7.3)a
416.4 (8.6)a
413.4 (8.8)a
467.7 (9.9)a
498.7 (9.6)a
Laparoscopic Roux-en-Y gastric bypass
618.1 (14.8)a
566.0 (11.9)a
491.0 (10.1)a
494.0 (10.5)a
551.9 (11.7)a
618.2 (11.9)a
Large-bowel procedure
245.0 (5.9)a
311.0 (6.6)a
306.8 (6.3)a
301.7 (6.4)a
250.2 (5.3)a
229.0 (4.4)a
a
a
a
a
a
Repair of abdominal wall hernia
211.0 (5.1)
228.5 (4.8)
247.4 (5.1)
236.5 (5.0)
230.9 (4.9)
248.2 (4.8)a
Thyroidectomy, partial or complete
138.2 (3.3)a
194.4 (4.1)a
208.5 (4.3)a
209.2 (4.4)a
197.1 (4.2)a
244.9 (4.7)a
Small-bowel procedure
103.4 (2.5)
222.5 (4.7)a
206.3 (4.3)a
195.4 (4.1)a
180.1 (3.8)a
192.4 (3.7)a
a
Laparoscopic esophagogastric procedure
187.7 (4.5)
171.2 (3.6)
143.6 (3.0)
142.0 (3.0)
196.0 (4.2)
386.6 (7.5)a
Mastectomy, partial or complete
113.3 (2.7)
114.9 (2.4)
176.0 (3.6)a
173.9 (3.7)a
335.4 (7.1)a
164.4 (3.2)a
Pancreatic resection, Whipple type
113.8 (2.7)
200.4 (4.2)a
235.6 (4.9)a
237.4 (5.0)a
130.4 (2.8)
201.1 (3.9)a
Repair of inguinal hernia
149.2 (3.6)a
129.0 (2.7)
171.3 (3.5)a
168.7 (3.6)a
175.6 (3.7)a
148.2 (2.9)
NA
94.3 (2.0)
a
208.6 (4.3)
a
209.0 (4.4)
144.7 (3.1)a
115.6 (2.2)
Intra-abdominal procedure
151.4 (3.6)a
178.6 (3.8)a
163.9 (3.4)
156.9 (3.3)
133.9 (2.8)
123.1 (2.4)
Nongeneral surgery
114.9 (2.8)a
169.6 (3.6)a
123.4 (2.5)
123.3 (2.6)
31.1 (0.7)
92.4 (1.8)
86.3 (2.1)
121.0 (2.6)
96.3 (2.0)
92.8 (2.0)
103.6 (2.2)
156.1 (3.0)a
167.9 (4.0)a
94.7 (2.0)
43.4 (0.9)
43.8 (0.9)
33.2 (0.7)
12.8 (0.2)
Laparoscopic adjustable gastric band procedure
Laparoscopic repair of abdominal wall hernia Gastric restrictive procedure
a
a
Abbreviations: NA, not applicable; wRVUs, work relative value units. a
Ranked in the top 10 wRVUs for the designated year from 2006 to 2011.
Table 5. Total Generated wRVUs in Academic General Surgery From 2006 to 2011 Mean wRVUs (% of All wRVUs) Surgical Category
2006
2007
2008
2009
2010
2011
Bariatric
786.0 (18.8)
755.0 (15.9)
743.0 (15.3)
746.8 (15.8)
729.7 (15.5)
863.7 (16.7)
Breast
205.0 (4.9)
207.0 (4.4)
280.3 (5.8)
266.7 (5.6)
470.6 (10.0)
225.3 (4.4)
Foregut
367.4 (8.8)
369.6 (7.8)
336.0 (6.9)
306.4 (6.5)
341.2 (7.2)
531.6 (10.3)
General abdomen
177.7 (4.3)
208.4 (4.4)
198.1 (4.1)
188.4 (4.0)
164.9 (3.5)
165.7 (3.2)
Hepatobiliary, pancreas, and solid organ
777.7 (18.6)
935.0 (19.7)
1022.1 (21.1)
998.1 (21.1)
884.4 (18.7)
1019.3 (19.7)
Hernia
501.1 (12.0)
534.5 (11.3)
576.5 (11.9)
555.9 (11.8)
587.1 (12.4)
663.3 (12.8)
Head, neck, and thoracic
309.2 (7.4)
381.5 (8.0)
416.6 (8.6)
413.5 (8.8)
380.6 (8.1)
451.4 (8.7)
Intestinal
820.9 (19.7)
1055.4 (22.3)
1066.2 (22.0)
1039.3 (22.0)
1009.4 (21.4)
989.4 (19.1)
Skin and soft tissue
111.4 (2.7)
123.3 (2.6)
90.0 (1.9)
84.4 (1.8)
120.7 (2.6)
176.0 (3.4)
Nongeneral surgery
114.9 (2.8)
169.6 (3.6)
123.4 (2.5)
123.3 (2.6)
31.1 (0.7)
92.4 (1.8)
Abbreviation: wRVUs, work relative value units.
wRVU generation, peaking at 498.7 in 2011 and representing 9.6% of all wRVUs. Procedures also consistently among the top 10 procedures in wRVU generation included large-bowel procedure (wRVU, 229.0-311.0), repair of abdominal wall hernia (wRVU, 211.0-248.2), and partial or complete thyroidectomy (wRVU, 138.2-244.9). Only laparoscopic RYGB and laparoscopic cholecystectomy consistently generated more than 400 wRVUs. Procedures with wRVUs greater than 300 in at least 1 year included laparoscopic esophagogastric procedure in 2011 (wRVU, 386.6), partial or complete mastectomy in 2010 (wRVU, jamasurgery.com
335.4), and large-bowel procedure in 2007 (wRVU, 311.0), 2008 (wRVU, 306.8), and 2009 (wRVU, 301.7). Overall, for surgical categories, intestinal surgery (wRVU, 820.9-1066.2) and hepatobiliary, pancreas, and solid-organ surgery (wRVU, 777.7-1022.1) had the highest total wRVUs each year and accounted for 38.3% to 43.1% of all generated wRVUs (Table 5). In all years, bariatric surgery (wRVU, 729.7863.7) was regularly among the top 3 highest-generating wRVUs, representing 15.3% to 18.8% of total procedures. Other key contributors to wRVU production were hernia surgery (Reprinted) JAMA Surgery February 2015 Volume 150, Number 2
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(wRVU, 501.1-663.3), foregut surgery (wRVU, 306.4-531.6), and head, neck, and thoracic surgery (wRVU, 309.2-451.4). The total wRVUs for bariatric surgery were primarily driven by the considerable effects of laparoscopic RYGB, and laparoscopic adjustable gastric band surgery ranked among the top 10 wRVU-generating procedures in 2008 (wRVU, 208.6), 2009 (wRVU, 209.0), and 2010 (wRVU, 144.7). In addition, laparoscopic sleeve gastrectomy as a specific CPT code debuted in the FPSC database in 2011.
Discussion The mean PFS and associated wRVUs from the FPSC database clearly signify a gradual shift in academic general surgery practice. The traditional procedures, such as appendectomy, cholecystectomy, herniorrhaphy, and endoscopy, were among the most commonly performed procedures during the 6-year period. Laparoscopic RYGB was also consistently among the most commonly performed procedure, and bariatric surgery represented 7% to 10% of all procedures under the general surgery specialty. Furthermore, laparoscopic RYGB was consistently the highest-generating wRVU procedure, and bariatric surgery represented 18% of all generated wRVUs by general surgery in the most recent 2011 FPSC data. The significant presence of bariatric procedures suggests an evolution in the scope of general surgery practice. The data may not delineate what percentage of bariatric procedures are performed by bariatric or minimally invasive surgeons, but the results are compelling that a change has occurred. In response to the increasing prevalence of patients undergoing bariatric surgery in a surgical practice, the American Society for Metabolic and Bariatric Surgery published a position statement on the acute care for complications related to bariatric surgery.6 Patients undergoing bariatric surgery with acute surgical conditions may present a major challenge for most general surgeons unless they are familiar with the anatomical and metabolic alterations of the common bariatric procedures. The FPSC data from 2006 to 2011 confirm the high frequency of performed bariatric procedures, and in time, the population of patients undergoing bariatric surgery will become a notable portion of all physician practices. In a statewide review, Michigan hospitals’ 30-day complication rates after bariatric surgery for bowel obstruction (1.5%), infection (3.2%), medical complications (1.5%), additional operation (1.7%), readmission (4.0%), and emergency department visits (6.8%) are indicative of the implications for the general surgeon.7 At a high-volume bariatric center, the 30-day readmission rates after bariatric surgery are 5% to 6%, and the 1-year readmission rates are 12% to 13%.8 Most patients with bariatric-related complications should be referred to a Bariatric Surgery Center of Excellence whose surgeons and facilities have the capabilities for management and care of the patient undergoing bariatric surgery. However, not all Bariatric Surgery Centers of Excellence are readily accessible, and general surgeons are often responsible for treating these patients. There is a significant trend in general surgery training toward basic and complex laparoscopic procedures.9 The ABS and 150
Resident Review Committee for Surgery do not specifically require operative training in bariatric procedures, but they have increased the requirement for complex laparoscopy (number of procedures, 0-25) for graduating general surgery residents. Subsequently, there is an increasing number of graduating general surgery residents entering fellowships for advanced gastrointestinal surgery to refine their laparoscopic skills.10 The ABS already expects general surgery residents to be competent in the surgical planning and postoperative care of patients undergoing bariatric surgery, and academic programs continue to integrate bariatric surgery in surgical residency training. The scope of general surgery practice continues to evolve through the decades of technologic discoveries and emerging evidence-based medicine. In the 1990s, the resident operative experience transitioned from open gastrointestinal procedures to more specialized ones.11,12 Several studies13-16 found that implementation of a focus on training surgical residents in advance laparoscopy has significant effect on patient outcomes. Specifically, laparoscopic RYGB provides the key components to develop important advanced laparoscopic techniques, which include gastric resection and pouch creation, jejunojejunostomy, and gastrojejunostomy, provide varying aspects of laparoscopic tissue mobilization, stapling, and suturing anastomoses.13,14,17 In our review, laparoscopic RYGB was uniformly one of the most commonly performed procedures among academic centers and would provide the perfect platform for surgical resident training in advance laparoscopic techniques. A review of the surgical operative log of more than 2400 general surgeons during recertification from 1995 to 1997 revealed that the mean number of procedures per general surgeon was 398, and laparoscopic and thoracoscopic operations accounted for 11% of the total procedures.18 An update on the practice patterns of general surgery from 2007 to 2009 reported that there was an increase in laparoscopic and thoracoscopic operations, accounting for 17% of the total procedures.19 Of the top 100 most commonly performed procedures, the mean frequency of complex laparoscopy increased from 13% to 23% from the 2006 to the 2011 FPSC calendar year. A cohort comparison of general surgeons according to the number of years since initial certification revealed a gradual increase in the mean number of laparoscopic procedures (26 in the 30-year group to 73 in the 10-year group).19 Younger general surgeons appeared to be more apt in laparoscopic techniques for basic and complex procedures. The FPSC database is composed of purely academic medical centers and therefore may not reflect the nonacademic general surgery practice. However, community general surgery practice is commonly more heterogeneous20 and is more likely to be confronted with the increasing presence of patients undergoing bariatric surgery. The ABS defines general surgeons under a broad umbrella, and subspecialization is becoming more common but is not specifically certified by the ABS. Subspecializations under general surgery include bariatric, breast, endocrine, and minimally invasive surgery. The ABS requires general surgeons, regardless of subspecialization and fo-
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cused practice, to be proficient in preoperative, perioperative, and postoperative care of patients within all these subspecialties.
Conclusions Patients undergoing bariatric surgery are becoming a prominent patient population in all medical and surgical specialties. We believe that general surgeons who include bariatric surgery as part of their practice should abide by the credentialing
ARTICLE INFORMATION Accepted for Publication: April 28, 2014. Published Online: December 23, 2014. doi:10.1001/jamasurg.2014.2242. Author Contributions: Drs Mostaedi and Galante had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: Mostaedi, Ali, Scherer. Drafting of the manuscript: Mostaedi, Ali, Scherer. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Mostaedi, Ali, Scherer. Administrative, technical, or material support: Mostaedi, Scherer. Study supervision: Ali, Pierce, Galante. Conflict of Interest Disclosures: None reported. Previous Presentations: This study, titled Current Academic Surgical Clinical Practice and Its Implications for Surgical Training, was presented at the American College of Surgeons 99th Annual Clinical Congress, The Committee on Scientific Posters, Division of Education; October 8, 2013; Washington, DC. REFERENCES 1. American Board of Surgery. Booklet of Information—Surgery, 2011-2012. Philadelphia, PA: American Board of Surgery; 2012. 2. American Board of Surgery. Booklet of Information, July 2003-June 2004. Philadelphia, PA: American Board of Surgery; 2004. 3. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303(3):235-241.
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guidelines proposed by the American Society for Metabolic and Bariatric Surgery and supported by the American College of Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. These data reveal that bariatric surgery is among the most frequently performed procedures in academic surgical practice. We believe that resident surgical training should continue to reevaluate its core curriculum to ensure that surgical graduates have received appropriate training. Bariatric surgery would provide ample opportunity for surgeons to improve laparoscopic technical expertise and become familiar with this increasing population of patients.
4. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA. 2012;307(5):491-497.
13. Iordens GI, Klaassen RA, van Lieshout EM, Cleffken BI, van der Harst E. How to train surgical residents to perform laparoscopic Roux-en-Y gastric bypass safely. World J Surg. 2012;36(9):2003-2010.
5. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4): 427-436.
14. Rovito PF, Kreitz K, Harrison TD, Miller MT, Shimer R. Laparoscopic Roux-en-Y gastric bypass and the role of the surgical resident. Am J Surg. 2005;189(1):33-37.
6. Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. American Society for Metabolic and Bariatric Surgery position statement on emergency care of patients with complications related to bariatric surgery. Surg Obes Relat Dis. 2010;6(2):115-117. 7. Birkmeyer NJ, Dimick JB, Share D, et al; Michigan Bariatric Surgery Collaborative. Hospital complication rates with bariatric surgery in Michigan. JAMA. 2010;304(4):435-442. 8. Saunders JK, Ballantyne GH, Belsley S, et al. 30-day readmission rates at a high volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and vertical banded gastroplasty-Roux-en-Y gastric bypass. Obes Surg. 2007;17(9):1171-1177.
15. McFadden CL, Cobb WS, Lokey JS, Cull DL, Smith DE, Taylor SM. The impact of a formal minimally invasive service on the resident’s ability to achieve new ACGME guidelines for laparoscopy. J Surg Educ. 2007;64(6):420-423. 16. 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):307-311. 17. Martin MJ, Eckert MJ, Eggebroten WE, Beekley AC. A new and simplified technique for laparoscopic gastric bypass in a residency training program: decreased resource utilization and enhanced training. Arch Surg. 2010;145(9):844-851.
9. Eckert M, Cuadrado D, Steele S, Brown T, Beekley A, Martin M. The changing face of the general surgeon: national and local trends in resident operative experience. Am J Surg. 2010;199 (5):652-656.
18. Ritchie WP Jr, Rhodes RS, Biester TW. Work loads and practice patterns of general surgeons in the United States, 1995-1997: a report from the American Board of Surgery. Ann Surg. 1999;230(4): 533-543.
10. Bell RH Jr. Graduate education in general surgery and its related specialties and subspecialties in the United States. World J Surg. 2008;32(10):2178-2184.
19. Valentine RJ, Jones A, Biester TW, Cogbill TH, Borman KR, Rhodes RS. General surgery workloads and practice patterns in the United States, 2007 to 2009: a 10-year update from the American Board of Surgery. Ann Surg. 2011;254(3):520-526.
11. Parsa CJ, Organ CH Jr, Barkan H. Changing patterns of resident operative experience from 1990 to 1997. Arch Surg. 2000;135(5):570-575. 12. Espat NJ, Ong ES, Helton WS, Nyhus LM. 1990-2001 US general surgery chief resident gastric surgery operative experience: analysis of paradigm shift. J Gastrointest Surg. 2004;8(4):471-478.
20. Rhodes RS. Defining general surgery and the core curriculum. Surg Clin North Am. 2004;84(6):1605-1619, xi.
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Bariatric Surgery and the Changing Current Scope of General Surgery Practice Implications for General Surgery Residency Training Rouzbeh Mostaedi, MD; Mohamed R. Ali, MD; Jonathan L. Pierce, MD; Lynette A. Scherer, MD; Joseph M. Galante, MD
IMPORTANCE The scope of general surgery practice has evolved tremendously in the last 20 years. However, clinical experience in general surgery residency training has undergone relatively little change. OBJECTIVE To evaluate the current scope of academic general surgery and its implications on surgical residency. DESIGN, SETTING, AND PARTICIPANTS The University HealthSystem Consortium and Association of American Medical Colleges established the Faculty Practice Solution Center (FPSC) to characterize physician productivity. The FPSC is a benchmarking tool for academic medical centers created from revenue data collected from more than 90 000 physicians who practice at 95 institutions across the United States. MAIN OUTCOMES AND MEASURES The FPSC database was queried to evaluate the annual mean procedure frequency per surgeon (PFS) in each calendar year from 2006 through 2011. The associated work relative value units (wRVUs) were also examined to measure physician effort and skill. RESULTS During the 6-year period, 146 distinct Current Procedural Terminology codes were among the top 100 procedures, and 16 of these procedures ranked in the top 10 procedures in at least 1 year. The top 10 procedures accounted for more than half (range, 52.5%-57.2%) of the total 100 PFS evaluated for each year. Laparoscopic Roux-en-Y gastric bypass was consistently among the top 10 procedures in each year (PFS, 18.2-24.6). The other most frequently performed procedures included laparoscopic cholecystectomy (PFS, 30.3-43.5), upper gastrointestinal tract endoscopy (PFS, 26.5-34.3), mastectomy (PFS, 16.5-35.0), inguinal hernia repair (PFS, 15.5-22.1), and abdominal wall hernia repair (PFS, 21.6-26.1). In all years, laparoscopic Roux-en-Y gastric bypass generated the highest number of wRVUs (wRVUs, 491.0-618.2), and laparoscopic cholecystectomy was regularly the next highest (wRVUs, 335.8-498.7). CONCLUSIONS AND RELEVANCE A significant proportion of academic general surgery is composed of bariatric surgery, yet surgical training does not sufficiently emphasize the necessary exposure to technical expertise and clinical management of the patient undergoing bariatric surgery. As the scope of general surgery practice continues to evolve, general surgery residency training will need to better integrate the exposure to bariatric surgery. Author Affiliations: Department of Surgery, University of California, Davis, Sacramento (Mostaedi, Ali, Pierce, Galante); Department of Trauma, Mercy San Juan Medical Center, Carmichael, California (Scherer).
JAMA Surg. 2015;150(2):144-151. doi:10.1001/jamasurg.2014.2242 Published online December 23, 2014. 144
Corresponding Author: Joseph M. Galante, MD, Department of Surgery, University of California, Davis, 2221 Stockton Blvd, Cypress Bldg, Sacramento, CA 95817 (joseph [email protected]). (Reprinted) jamasurgery.com
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Bariatric Surgery
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T
he American Board of Surgery (ABS) defines general surgery as a “discipline that requires knowledge of and familiarity with a broad spectrum of diseases that may require surgical treatment.” 1(p5) The domain of expertise encompassed by general surgery is a heterogeneous understanding of anatomy, physiology, and technical capability of treating the surgical patient.2 Since 2004, the ABS stated that the “certified general surgeon is expected to have knowledge and skills in the management and team-based interdisciplinary care of morbidly obese patients, to include metabolic derangements, weight loss surgery and the counseling of patients and families.”1(p1)2 General surgeons must actively familiarize themselves with the conditions that face patients undergoing bariatric surgery because the patients are clinically morbidly obese. The prevalence of obesity in the United States has been increasing in the last decade, and an epidemiologic survey revealed that approximately 36% of the adult population is obese.3,4 In response to the obesity epidemic and the efficacy of surgical weight loss, the annual number of bariatric operations is more than 100 000 in the United States and more than 340 000 worldwide in 2011.5 At our own institution, we have witnessed the increasing frequency of patients undergoing bariatric surgery who are being cared by medical specialists, and this patient population will continue to have an increasing presence in the practices of primary care physicians and all specialized surgical physicians. We hypothesize that bariatric surgery comprises a substantial proportion of current academic surgical practice. We sought to describe the national trend of general surgery practice at academic medical centers in the United States and its implications for the scope of general surgery residency training.
Methods The University of California Institutional Review Board approved this study as exempt because no patient data were included in the study. Colleges established the Faculty Practice Solution Center (FPSC) to more accurately characterize physician productivity. The FPSC is a national benchmarking tool for academic medical centers created from revenue data collected from more than 90 000 physicians who practice at 95 institutions across the United States. Faculty physicians who are clinically active for more than 60% of their time within a specific specialty are included in the benchmarking process. Within the FPSC, surgery is subcategorized into general, trauma, burn, thoracic, cardiac, plastic, oncology, vascular, pediatric, and transplant surgery. Each faculty surgeon is uniquely classified into one these specialties by the academic medical centers to avoid any physician crossover into multiple specialties. Each year, approximately 250 of these surgeons are classified in the general surgery specialty. However, the FPSC database does not separately categorize minimally invasive surgery or bariatric surgery. We assume that surgeons who perform these procedures are included within the general surgery specialty. jamasurgery.com
The information from the FPSC database includes Current Procedural Terminology (CPT) codes and associated relative value units (RVUs). The CPT codes provide standardized reporting of physician services. In this study, we evaluated the reported annual mean procedure frequency per surgeon (PFS). The PFS is defined as the mean number of each CPT-coded procedure performed by a general surgeon during each year. The RVUs attached to a CPT code are indicative of the effort required to perform the service. To more specifically target the level of time, skill, training, and intensity required to provide a service, we focused on the physician work RVUs (wRVUs). For example, the wRVUs for the laparoscopic Roux-en-Y gastric bypass (RYGB) and Whipple procedures are 3.7 and 6.6 times greater than the repair of the inguinal hernia, respectively. Deidentified coding and billing information was extracted from the FPSC database for the calendar years 2006 through 2011. A filtering method was designed and is detailed in the Figure. Only data from the general surgery specialty were used, and data from the other 9 previously listed surgical specialties were excluded. The total reported CPT codes for general surgery ranged from 1965 to 2320, depending on the year. To identify commonly performed operations, the CPT codes for each year were sorted by PFS from highest to lowest. Each CPT code was individually evaluated. The evaluation and management CPT codes were excluded to focus only on procedure CPT codes. We used the ABS to only include defined procedures and exclude procedures listed “not for major credit” (n = 83). For example, minor procedures, such as tube thoracostomy placement, central catheter placement, and simple incision and drainage, were excluded from the study. Furthermore, we focused on CPT codes considered “primary” procedures and excluded procedures labeled “list separately in addition to primary procedure” (n = 23). The filtering method was applied to each CPT code until the 100 most frequently performed procedures were selected for each year from 2006 through 2011. The CPT codes were organized into 10 surgical categories based on procedure type and organ system (Table 1). For example, the hepatobiliary, pancreas, and solid-organ surgery category is consolidated into 6 generalized procedures: (1) cholecystectomy, (2) laparoscopic cholecystectomy, (3) hepatobiliary and solid-organ procedures, (4) laparoscopic hepatobiliary and solid-organ procedures, (5) pancreatic resection, Whipple type, and (6) pancreatic procedures. In addition, the CPT codes were categorized into more generalized procedures. The CPT codes for laparoscopic cholecystectomy without cholangiography (CPT code 47562) and laparoscopic cholecystectomy with cholangiography (CPT code 47563) are listed as a single general procedure—laparoscopic cholecystectomy.
Results The list of the 100 most frequently performed procedures varied from year to year. Thus, 146 unique CPT codes were identified to have been among the 100 most frequently performed procedures during the entire study period (Table 1). The (Reprinted) JAMA Surgery February 2015 Volume 150, Number 2
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Figure. Current Procedural Terminology (CPT) Code Filter Method for the Top 100 Most Frequently Performed Procedures All surgery Reported CPT codes
Speciality surgery Trauma Plastic Oncology Burn Vascular Thoracic Pediatric Cardiac Transplant
General surgery 1965-2320 Total CPT codes for each year from 2006 to 2011
CPT codes sorted by PFS from highest to lowest
“Procedure” CPT code?
No
Excluded CPT codes designated “evaluation and management”
No
Excluded CPT codes listed as “not for major credit” by the ABS
Yes ABS “defined” procedure?
Repeat for each CPT code until top 100 procedures reached
Yes ABS “primary” procedure?
No
Excluded CPT codes listed as “list separately in addition to primary procedure”
Yes
Accepted as a top 100 ABS “defined primary procedure” in general surgery for each year from 2006 to 2011
146 Unique CPT codes appeared in the top 100 procedures in at least one year from 2006 to 2011
ABS indicates American Board of Surgery; PFS, procedure frequency per surgeon.
nonselected codes all had a PFS less than 2, indicating that academic surgeons performed fewer than 2 of these procedures per year.
Procedure Frequency per Surgeon The PFS for the 100 CPT codes were compared, and the most frequently performed procedures from 2006 through 2011 are listed in Table 2. In all years, these 100 CPT codes represented a significant bulk of ABS-defined primary operations. Overall, 16 procedures were among the 10 most commonly performed procedures at least once from 2006 through 2011. Each year, the top 10 procedures accounted for more than half (range, 52.5%-57.2%) of the total top 100 procedures. Consistently, 6 operations ranked among the top 10 most commonly performed procedures every year (Table 2). Laparoscopic cholecystectomy (PFS, 30.3-43.5), upper gastrointestinal tract endoscopy (PFS, 26.5-34.3), laparoscopic RYGB (PFS, 18.2-24.6), partial or complete mastectomy (PFS, 16.5-35.0), inguinal hernia repair (PFS, 15.5-22.1), and abdominal wall hernia repair (PFS, 21.6-26.1) combined to represent at least 37% of the top 100 procedures performed by academic general surgeons. Individually, the mean PFS for laparoscopic cholecystectomy increased annually and peaked in 2011 (PFS, 43.5) and represented 11.1% of the top 100 procedures. Laparoscopic RYGB comprised 4.8% to 6.7% of all procedures. The 2 hernia operations represented at least 10% of academic general sur146
gery practice. Although upper gastrointestinal tract endoscopy was one of the most frequently performed procedures in all years, lower gastrointestinal tract endoscopy was also a prevalent procedure that ranked among the top 10 in 5 of the 6 years. In total, these 2 procedures accounted for 10.1% to 13.8% of the top 100 procedures. The PFS was examined for each surgical category (Table 3). The categories of hepatobiliary, pancreas, and solid-organ surgery (PFS, 53.6-66.0), hernia surgery (PFS, 53.1-70.7), and intestinal surgery (PFS, 66.8-75.5) were the only 3 surgical categories with a PFS greater than 50 in all years. These surgical categories individually represented a significant proportion (range, 14%-21%) of all procedures, and in total they constituted up to 57% of general surgery practice. Of the remaining surgical categories, foregut surgery (PFS, 46.6-57.0); head, neck, and thoracic surgery (PFS, 31.2-36.9); and breast surgery (PFS, 27.1-54.5) were commonly performed and additionally represented the breadth of general surgery. Bariatric surgery (PFS, 29.4-35.6) was common in all years and peaked in 2011 (Table 3). In addition to laparoscopic RYGB, laparoscopic adjustable gastric band surgery was among the top 10 most frequently performed procedures in 2008 (PFS, 12.4) and 2009 (PFS, 12.5). The PFS for gastric restrictive procedures precipitously decreased from 2006 to 2011 as more specific bariatric CPT codes became available. In 2010, the CPT code for laparoscopic sleeve gastrectomy was introduced, and
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Table 1. CPT Codes Consolidated Into Surgical Categories CPT Code(s)
Surgical Category Bariatric Gastric restrictive procedure
43843, 43846
Laparoscopic Roux-en-Y gastric bypass
43644
Laparoscopic adjustable gastric band procedure
43770, 43774
Laparoscopic sleeve gastrectomy
43775
Breast Mastectomy, partial or complete
19120, 19125, 19160, 19180, 19301, 19303
Mastectomy, with axillary lymphadenectomy Axillary lymphadenectomy, biopsy or complete
19162, 19240, 19302, 19307 38500, 38525, 38745
Foregut Upper gastrointestinal tract endoscopy, diagnostic and therapeutic Esophagogastric procedure
43234, 43235, 43239, 43245, 43246, 43249, 43262, 43750 43820, 43830, 43840, 43999
Laparoscopic esophagogastric procedure
43279, 43280, 43281, 43282, 43289, 43659
General abdomen Intra-abdominal procedure
22558, 38747, 49000, 49002, 49020, 49999
Laparoscopic intra-abdominal procedure
49320, 49321, 49329
Hepatobiliary, pancreas, and solid organ Cholecystectomy
47600, 47605
Laparoscopic cholecystectomy
47562, 47563
Hepatobiliary and solid-organ procedure
38100, 47100, 47120, 47780
Laparoscopic hepatobiliary and solid-organ procedure
38120, 47379, 58662, 60650
Pancreatic resection, Whipple type
48150, 48153
Pancreatic procedure
48005, 48140, 48999
Hernia Repair of inguinal hernia
49505, 49507, 49520
Laparoscopic repair of inguinal hernia Repair of abdominal wall hernia
49650, 49651 49560, 49561, 49565, 49566, 49585, 49587
Laparoscopic repair of abdominal wall hernia
49652, 49653, 49654, 49655, 49659
Head, neck, and thoracic Upper and lower airway endoscopy, diagnostic or therapeutic Thyroidectomy, partial or complete
31575, 31622, 31624, 31646 60220, 60225, 60240, 60252, 60260, 60271
Parathyroidectomy
60500
Head, neck, and thoracic procedure, nonendocrine
21555, 31600, 38510, 38724
Intestinal Lower gastrointestinal tract endoscopy, diagnostic or therapeutic Small-bowel procedure
45378, 45380, 45384, 45385 44005, 44120, 44130
Laparoscopic small-bowel procedure Large-bowel procedure
44180, 44200, 44202, 44238 44140, 44143, 44145, 44150, 44160
Laparoscopic large-bowel procedure
44204, 44205, 44207
Appendectomy
44950
Laparoscopic appendectomy
44970
Enterostomy, creation or closure
44300, 44310, 44320, 44620, 44625, 44626
Repair of bowel injury, perforation or fistula Anorectal procedure
44602, 44604, 44640 46040, 46255, 46260, 46270
Skin and soft tissue Skin graft or soft tissue flap
15100, 15120, 15300, 15350, 15430, 15734
Excision of skin or soft tissue lesions
11606, 21930, 21931
Surgical wound procedures, debridement or preparation
11043, 11044, 13160, 15000, 15002, 15004
Nongeneral surgery Nongeneral surgery
33533, 36200, 47135, 50360, 50547
Abbreviation: CPT, Current Procedural Terminology.
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Table 2. Highest PFS in Academic General Surgery From 2006 to 2011 Mean PFS (% of Total Procedures) Procedure
2006
2007
2009
2010
2011
Laparoscopic cholecystectomy
30.3 (8.3)a
30.4 (8.1)a
36.0 (9.5)a
36.1 (9.5)a
40.9 (10.4)a
43.5 (11.1)a
Laparoscopic Roux-en-Y gastric bypass
24.6 (6.7)a
20.8 (5.6)a
18.2 (4.8)a
18.3 (4.8)a
19.7 (5.0)a
22.0 (5.6)a
Mastectomy, partial or complete
18.2 (5.0)a
17.3 (4.6)a
19.2 (5.1)a
19.4 (5.1)a
35.0 (9.1)a
16.5 (4.2)a
Repair of inguinal hernia
18.6 (5.1)a
15.5 (4.1)a
20.6 (5.4)a
20.7 (5.5)a
22.1 (5.7)a
17.9 (4.6)a
Repair of abdominal wall hernia
a
21.6 (5.9)
a
22.7 (6.1)
a
24.1 (6.4)
a
24.2 (6.4)
a
24.5 (6.3)
26.1 (6.7)a
Upper gastrointestinal tract endoscopy, diagnostic and therapeutic
32.1 (8.8)a
34.3 (9.2)a
29.3 (7.7)a
29.2 (7.7)a
26.5 (6.8)a
29.9 (7.7)a
Lower gastrointestinal endoscopy, diagnostic or therapeutic
11.4 (3.1)a
17.2 (4.6)a
12.4 (12.4)a
12.4 (3.3)a
14.0 (3.6)a
9.7 (2.5)
Thyroidectomy, partial or complete
9.0 (2.4)
12.3 (3.3)a
13.4 (3.5)a
13.4 (3.6)a
13.3 (3.4)a
15.6 (4.0)a
11.8 (3.2)a
13.5 (3.6)a
12.9 (3.4)a
12.9 (3.4)a
10.8 (2.8)
9.8 (2.5)
a
a
Large-bowel procedure
2008
13.0 (3.6)
12.5 (3.3)
12.0 (3.2)
11.8 (3.1)
8.9 (2.3)
8.0 (2.0)
Laparoscopic adjustable gastric band procedure
NA
5.7 (1.5)
12.4 (3.3)a
12.5 (3.3)a
8.4 (2.2)
7.3 (1.9)
Small-bowel procedure
11.9 (3.2)a
11.9 (3.2)
10.9 (2.9)
10.9 (2.9)
9.8 (2.5)
11.1 (2.9)a
Intra-abdominal procedure
Axillary lymphadenectomy, biopsy or complete
10.0 (2.7)
Laparoscopic appendectomy
9.4 (2.5)
11.7 (3.1)
11.7 (3.1)
a
9.4 (2.4)
a
16.0 (4.2)
8.2 (2.2)
7.7 (2.1)
11.2 (3.0)
11.2 (3.0)
12.1 (3.1)
10.7 (2.8)
Laparoscopic esophagogastric procedure
11.3 (3.1)
9.0 (2.4)
7.9 (2.1)
7.9 (2.1)
10.0 (2.6)
17.8 (4.5)a
Laparoscopic repair of inguinal hernia
7.3 (2.0)
7.5 (2.0)
8.1 (2.1)
8.1 (2.1)
10.8 (2.8)
15.6 (4.0)a
Abbreviations: NA, not applicable; PFS, mean procedure frequency per surgeon. a
Ranked in the top 10 procedures for the designated year from 2006 to 2011.
Table 3. Total PFS in Academic General Surgery From 2006 to 2011 Mean PFS (% of Total Procedures) Surgical Category
2006
2007
2008 32.2 (8.5)
2009 32.5 (8.6)
2010 29.4 (7.5)
2011
Bariatric
31.9 (8.8)
30.0 (8.0)
35.6 (9.1)
Breast
30.8 (8.4)
29.2 (7.8)
33.1 (8.8)
33.3 (8.8)
54.5 (13.9)
27.1 (6.9)
Foregut
53.8 (14.7)
53.8 (14.4)
49.2 (13.0)
49.2 (13.0)
46.6 (11.9)
57.0 (14.6)
General abdomen
17.9 (4.9)
17.8 (4.8)
18.3 (4.8)
18.1 (4.8)
13.6 (3.5)
13.8 (3.5)
Hepatobiliary, pancreas, and solid organ
53.6 (14.7)
56.2 (15.0)
60.7 (16.1)
60.9 (16.1)
60.8 (15.5)
66.0 (16.9)
Hernia
54.5 (14.9)
53.1 (14.2)
59.8 (15.8)
60.1 (15.9)
64.9 (16.6)
70.7 (18.1)
Head, neck, and thoracic
31.2 (8.6)
33.6 (9.0)
36.9 (9.8)
36.9 (9.7)
33.9 (8.7)
32.9 (8.4)
Intestinal
68.7 (18.8)
75.5 (20.2)
71.2 (18.8)
71.2 (18.8)
72.3 (18.5)
66.8 (17.1)
Skin and soft tissue
18.5 (5.1)
19.6 (5.3)
12.5 (3.3)
4.1 (1.1)
14.6 (3.7)
2.7 (0.7)
Nongeneral surgery
4.1 (1.1)
4.7 (1.2)
4.1 (1.1)
12.3 (3.3)
0.9 (0.2)
18.1 (4.6)
Abbreviation: PFS, mean procedure frequency per surgeon.
the frequency of laparoscopic sleeve gastrectomy (PFS, 5.8) had already begun to approach laparoscopic adjustable gastric band surgery (PFS, 7.3) in 2011.
Work Relative Value Units Each unique CPT code has an assigned wRVU that indicates the skill and effort required to perform the specific procedure. The wRVUs assigned to each of the 100 procedures with the highest PFS were evaluated (Table 4). 148
In all years, laparoscopic RYGB generated the highest wRVUs per academic surgeon. This procedure consistently accounted for more than 10% of the annual wRVUs generated of the 100 most frequently performed procedures. In 2006, the generated wRVU for laparoscopic RYGB was 618.1, which represented 14.8% of all wRVUs. After a slight decrease in the intervening years, this procedure returned to its high wRVU in 2011 (618.2, which represented 11.9% of all wRVUs). Laparoscopic cholecystectomy was consistently second highest in
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Table 4. Highest Generated wRVUs in Academic General Surgery From 2006 to 2011 Mean wRVUs (% of All wRVUs) Procedure
2006
2007
2008
2009
2010
2011
Laparoscopic cholecystectomy
335.8 (8.0)a
347.9 (7.3)a
416.4 (8.6)a
413.4 (8.8)a
467.7 (9.9)a
498.7 (9.6)a
Laparoscopic Roux-en-Y gastric bypass
618.1 (14.8)a
566.0 (11.9)a
491.0 (10.1)a
494.0 (10.5)a
551.9 (11.7)a
618.2 (11.9)a
Large-bowel procedure
245.0 (5.9)a
311.0 (6.6)a
306.8 (6.3)a
301.7 (6.4)a
250.2 (5.3)a
229.0 (4.4)a
a
a
a
a
a
Repair of abdominal wall hernia
211.0 (5.1)
228.5 (4.8)
247.4 (5.1)
236.5 (5.0)
230.9 (4.9)
248.2 (4.8)a
Thyroidectomy, partial or complete
138.2 (3.3)a
194.4 (4.1)a
208.5 (4.3)a
209.2 (4.4)a
197.1 (4.2)a
244.9 (4.7)a
Small-bowel procedure
103.4 (2.5)
222.5 (4.7)a
206.3 (4.3)a
195.4 (4.1)a
180.1 (3.8)a
192.4 (3.7)a
a
Laparoscopic esophagogastric procedure
187.7 (4.5)
171.2 (3.6)
143.6 (3.0)
142.0 (3.0)
196.0 (4.2)
386.6 (7.5)a
Mastectomy, partial or complete
113.3 (2.7)
114.9 (2.4)
176.0 (3.6)a
173.9 (3.7)a
335.4 (7.1)a
164.4 (3.2)a
Pancreatic resection, Whipple type
113.8 (2.7)
200.4 (4.2)a
235.6 (4.9)a
237.4 (5.0)a
130.4 (2.8)
201.1 (3.9)a
Repair of inguinal hernia
149.2 (3.6)a
129.0 (2.7)
171.3 (3.5)a
168.7 (3.6)a
175.6 (3.7)a
148.2 (2.9)
NA
94.3 (2.0)
a
208.6 (4.3)
a
209.0 (4.4)
144.7 (3.1)a
115.6 (2.2)
Intra-abdominal procedure
151.4 (3.6)a
178.6 (3.8)a
163.9 (3.4)
156.9 (3.3)
133.9 (2.8)
123.1 (2.4)
Nongeneral surgery
114.9 (2.8)a
169.6 (3.6)a
123.4 (2.5)
123.3 (2.6)
31.1 (0.7)
92.4 (1.8)
86.3 (2.1)
121.0 (2.6)
96.3 (2.0)
92.8 (2.0)
103.6 (2.2)
156.1 (3.0)a
167.9 (4.0)a
94.7 (2.0)
43.4 (0.9)
43.8 (0.9)
33.2 (0.7)
12.8 (0.2)
Laparoscopic adjustable gastric band procedure
Laparoscopic repair of abdominal wall hernia Gastric restrictive procedure
a
a
Abbreviations: NA, not applicable; wRVUs, work relative value units. a
Ranked in the top 10 wRVUs for the designated year from 2006 to 2011.
Table 5. Total Generated wRVUs in Academic General Surgery From 2006 to 2011 Mean wRVUs (% of All wRVUs) Surgical Category
2006
2007
2008
2009
2010
2011
Bariatric
786.0 (18.8)
755.0 (15.9)
743.0 (15.3)
746.8 (15.8)
729.7 (15.5)
863.7 (16.7)
Breast
205.0 (4.9)
207.0 (4.4)
280.3 (5.8)
266.7 (5.6)
470.6 (10.0)
225.3 (4.4)
Foregut
367.4 (8.8)
369.6 (7.8)
336.0 (6.9)
306.4 (6.5)
341.2 (7.2)
531.6 (10.3)
General abdomen
177.7 (4.3)
208.4 (4.4)
198.1 (4.1)
188.4 (4.0)
164.9 (3.5)
165.7 (3.2)
Hepatobiliary, pancreas, and solid organ
777.7 (18.6)
935.0 (19.7)
1022.1 (21.1)
998.1 (21.1)
884.4 (18.7)
1019.3 (19.7)
Hernia
501.1 (12.0)
534.5 (11.3)
576.5 (11.9)
555.9 (11.8)
587.1 (12.4)
663.3 (12.8)
Head, neck, and thoracic
309.2 (7.4)
381.5 (8.0)
416.6 (8.6)
413.5 (8.8)
380.6 (8.1)
451.4 (8.7)
Intestinal
820.9 (19.7)
1055.4 (22.3)
1066.2 (22.0)
1039.3 (22.0)
1009.4 (21.4)
989.4 (19.1)
Skin and soft tissue
111.4 (2.7)
123.3 (2.6)
90.0 (1.9)
84.4 (1.8)
120.7 (2.6)
176.0 (3.4)
Nongeneral surgery
114.9 (2.8)
169.6 (3.6)
123.4 (2.5)
123.3 (2.6)
31.1 (0.7)
92.4 (1.8)
Abbreviation: wRVUs, work relative value units.
wRVU generation, peaking at 498.7 in 2011 and representing 9.6% of all wRVUs. Procedures also consistently among the top 10 procedures in wRVU generation included large-bowel procedure (wRVU, 229.0-311.0), repair of abdominal wall hernia (wRVU, 211.0-248.2), and partial or complete thyroidectomy (wRVU, 138.2-244.9). Only laparoscopic RYGB and laparoscopic cholecystectomy consistently generated more than 400 wRVUs. Procedures with wRVUs greater than 300 in at least 1 year included laparoscopic esophagogastric procedure in 2011 (wRVU, 386.6), partial or complete mastectomy in 2010 (wRVU, jamasurgery.com
335.4), and large-bowel procedure in 2007 (wRVU, 311.0), 2008 (wRVU, 306.8), and 2009 (wRVU, 301.7). Overall, for surgical categories, intestinal surgery (wRVU, 820.9-1066.2) and hepatobiliary, pancreas, and solid-organ surgery (wRVU, 777.7-1022.1) had the highest total wRVUs each year and accounted for 38.3% to 43.1% of all generated wRVUs (Table 5). In all years, bariatric surgery (wRVU, 729.7863.7) was regularly among the top 3 highest-generating wRVUs, representing 15.3% to 18.8% of total procedures. Other key contributors to wRVU production were hernia surgery (Reprinted) JAMA Surgery February 2015 Volume 150, Number 2
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(wRVU, 501.1-663.3), foregut surgery (wRVU, 306.4-531.6), and head, neck, and thoracic surgery (wRVU, 309.2-451.4). The total wRVUs for bariatric surgery were primarily driven by the considerable effects of laparoscopic RYGB, and laparoscopic adjustable gastric band surgery ranked among the top 10 wRVU-generating procedures in 2008 (wRVU, 208.6), 2009 (wRVU, 209.0), and 2010 (wRVU, 144.7). In addition, laparoscopic sleeve gastrectomy as a specific CPT code debuted in the FPSC database in 2011.
Discussion The mean PFS and associated wRVUs from the FPSC database clearly signify a gradual shift in academic general surgery practice. The traditional procedures, such as appendectomy, cholecystectomy, herniorrhaphy, and endoscopy, were among the most commonly performed procedures during the 6-year period. Laparoscopic RYGB was also consistently among the most commonly performed procedure, and bariatric surgery represented 7% to 10% of all procedures under the general surgery specialty. Furthermore, laparoscopic RYGB was consistently the highest-generating wRVU procedure, and bariatric surgery represented 18% of all generated wRVUs by general surgery in the most recent 2011 FPSC data. The significant presence of bariatric procedures suggests an evolution in the scope of general surgery practice. The data may not delineate what percentage of bariatric procedures are performed by bariatric or minimally invasive surgeons, but the results are compelling that a change has occurred. In response to the increasing prevalence of patients undergoing bariatric surgery in a surgical practice, the American Society for Metabolic and Bariatric Surgery published a position statement on the acute care for complications related to bariatric surgery.6 Patients undergoing bariatric surgery with acute surgical conditions may present a major challenge for most general surgeons unless they are familiar with the anatomical and metabolic alterations of the common bariatric procedures. The FPSC data from 2006 to 2011 confirm the high frequency of performed bariatric procedures, and in time, the population of patients undergoing bariatric surgery will become a notable portion of all physician practices. In a statewide review, Michigan hospitals’ 30-day complication rates after bariatric surgery for bowel obstruction (1.5%), infection (3.2%), medical complications (1.5%), additional operation (1.7%), readmission (4.0%), and emergency department visits (6.8%) are indicative of the implications for the general surgeon.7 At a high-volume bariatric center, the 30-day readmission rates after bariatric surgery are 5% to 6%, and the 1-year readmission rates are 12% to 13%.8 Most patients with bariatric-related complications should be referred to a Bariatric Surgery Center of Excellence whose surgeons and facilities have the capabilities for management and care of the patient undergoing bariatric surgery. However, not all Bariatric Surgery Centers of Excellence are readily accessible, and general surgeons are often responsible for treating these patients. There is a significant trend in general surgery training toward basic and complex laparoscopic procedures.9 The ABS and 150
Resident Review Committee for Surgery do not specifically require operative training in bariatric procedures, but they have increased the requirement for complex laparoscopy (number of procedures, 0-25) for graduating general surgery residents. Subsequently, there is an increasing number of graduating general surgery residents entering fellowships for advanced gastrointestinal surgery to refine their laparoscopic skills.10 The ABS already expects general surgery residents to be competent in the surgical planning and postoperative care of patients undergoing bariatric surgery, and academic programs continue to integrate bariatric surgery in surgical residency training. The scope of general surgery practice continues to evolve through the decades of technologic discoveries and emerging evidence-based medicine. In the 1990s, the resident operative experience transitioned from open gastrointestinal procedures to more specialized ones.11,12 Several studies13-16 found that implementation of a focus on training surgical residents in advance laparoscopy has significant effect on patient outcomes. Specifically, laparoscopic RYGB provides the key components to develop important advanced laparoscopic techniques, which include gastric resection and pouch creation, jejunojejunostomy, and gastrojejunostomy, provide varying aspects of laparoscopic tissue mobilization, stapling, and suturing anastomoses.13,14,17 In our review, laparoscopic RYGB was uniformly one of the most commonly performed procedures among academic centers and would provide the perfect platform for surgical resident training in advance laparoscopic techniques. A review of the surgical operative log of more than 2400 general surgeons during recertification from 1995 to 1997 revealed that the mean number of procedures per general surgeon was 398, and laparoscopic and thoracoscopic operations accounted for 11% of the total procedures.18 An update on the practice patterns of general surgery from 2007 to 2009 reported that there was an increase in laparoscopic and thoracoscopic operations, accounting for 17% of the total procedures.19 Of the top 100 most commonly performed procedures, the mean frequency of complex laparoscopy increased from 13% to 23% from the 2006 to the 2011 FPSC calendar year. A cohort comparison of general surgeons according to the number of years since initial certification revealed a gradual increase in the mean number of laparoscopic procedures (26 in the 30-year group to 73 in the 10-year group).19 Younger general surgeons appeared to be more apt in laparoscopic techniques for basic and complex procedures. The FPSC database is composed of purely academic medical centers and therefore may not reflect the nonacademic general surgery practice. However, community general surgery practice is commonly more heterogeneous20 and is more likely to be confronted with the increasing presence of patients undergoing bariatric surgery. The ABS defines general surgeons under a broad umbrella, and subspecialization is becoming more common but is not specifically certified by the ABS. Subspecializations under general surgery include bariatric, breast, endocrine, and minimally invasive surgery. The ABS requires general surgeons, regardless of subspecialization and fo-
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cused practice, to be proficient in preoperative, perioperative, and postoperative care of patients within all these subspecialties.
Conclusions Patients undergoing bariatric surgery are becoming a prominent patient population in all medical and surgical specialties. We believe that general surgeons who include bariatric surgery as part of their practice should abide by the credentialing
ARTICLE INFORMATION Accepted for Publication: April 28, 2014. Published Online: December 23, 2014. doi:10.1001/jamasurg.2014.2242. Author Contributions: Drs Mostaedi and Galante had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: Mostaedi, Ali, Scherer. Drafting of the manuscript: Mostaedi, Ali, Scherer. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Mostaedi, Ali, Scherer. Administrative, technical, or material support: Mostaedi, Scherer. Study supervision: Ali, Pierce, Galante. Conflict of Interest Disclosures: None reported. Previous Presentations: This study, titled Current Academic Surgical Clinical Practice and Its Implications for Surgical Training, was presented at the American College of Surgeons 99th Annual Clinical Congress, The Committee on Scientific Posters, Division of Education; October 8, 2013; Washington, DC. REFERENCES 1. American Board of Surgery. Booklet of Information—Surgery, 2011-2012. Philadelphia, PA: American Board of Surgery; 2012. 2. American Board of Surgery. Booklet of Information, July 2003-June 2004. Philadelphia, PA: American Board of Surgery; 2004. 3. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303(3):235-241.
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guidelines proposed by the American Society for Metabolic and Bariatric Surgery and supported by the American College of Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. These data reveal that bariatric surgery is among the most frequently performed procedures in academic surgical practice. We believe that resident surgical training should continue to reevaluate its core curriculum to ensure that surgical graduates have received appropriate training. Bariatric surgery would provide ample opportunity for surgeons to improve laparoscopic technical expertise and become familiar with this increasing population of patients.
4. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA. 2012;307(5):491-497.
13. Iordens GI, Klaassen RA, van Lieshout EM, Cleffken BI, van der Harst E. How to train surgical residents to perform laparoscopic Roux-en-Y gastric bypass safely. World J Surg. 2012;36(9):2003-2010.
5. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4): 427-436.
14. Rovito PF, Kreitz K, Harrison TD, Miller MT, Shimer R. Laparoscopic Roux-en-Y gastric bypass and the role of the surgical resident. Am J Surg. 2005;189(1):33-37.
6. Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. American Society for Metabolic and Bariatric Surgery position statement on emergency care of patients with complications related to bariatric surgery. Surg Obes Relat Dis. 2010;6(2):115-117. 7. Birkmeyer NJ, Dimick JB, Share D, et al; Michigan Bariatric Surgery Collaborative. Hospital complication rates with bariatric surgery in Michigan. JAMA. 2010;304(4):435-442. 8. Saunders JK, Ballantyne GH, Belsley S, et al. 30-day readmission rates at a high volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and vertical banded gastroplasty-Roux-en-Y gastric bypass. Obes Surg. 2007;17(9):1171-1177.
15. McFadden CL, Cobb WS, Lokey JS, Cull DL, Smith DE, Taylor SM. The impact of a formal minimally invasive service on the resident’s ability to achieve new ACGME guidelines for laparoscopy. J Surg Educ. 2007;64(6):420-423. 16. 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):307-311. 17. Martin MJ, Eckert MJ, Eggebroten WE, Beekley AC. A new and simplified technique for laparoscopic gastric bypass in a residency training program: decreased resource utilization and enhanced training. Arch Surg. 2010;145(9):844-851.
9. Eckert M, Cuadrado D, Steele S, Brown T, Beekley A, Martin M. The changing face of the general surgeon: national and local trends in resident operative experience. Am J Surg. 2010;199 (5):652-656.
18. Ritchie WP Jr, Rhodes RS, Biester TW. Work loads and practice patterns of general surgeons in the United States, 1995-1997: a report from the American Board of Surgery. Ann Surg. 1999;230(4): 533-543.
10. Bell RH Jr. Graduate education in general surgery and its related specialties and subspecialties in the United States. World J Surg. 2008;32(10):2178-2184.
19. Valentine RJ, Jones A, Biester TW, Cogbill TH, Borman KR, Rhodes RS. General surgery workloads and practice patterns in the United States, 2007 to 2009: a 10-year update from the American Board of Surgery. Ann Surg. 2011;254(3):520-526.
11. Parsa CJ, Organ CH Jr, Barkan H. Changing patterns of resident operative experience from 1990 to 1997. Arch Surg. 2000;135(5):570-575. 12. Espat NJ, Ong ES, Helton WS, Nyhus LM. 1990-2001 US general surgery chief resident gastric surgery operative experience: analysis of paradigm shift. J Gastrointest Surg. 2004;8(4):471-478.
20. Rhodes RS. Defining general surgery and the core curriculum. Surg Clin North Am. 2004;84(6):1605-1619, xi.
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