Original ReportsVariable Operative Experience in Hand Surgery for Plastic Surgery Residents☆
Introduction
The Accreditation Council for Graduate Medical Education (ACGME) requires plastic surgery residents to receive competency training in hand surgery.1, 2 One critical aspect of competency training during plastic surgery residency is case volume.3 Although imperfect, case minimums afford a basic threshold for accrediting bodies like the ACGME.4 As operative proficiency and clinical outcomes correlate with case volume,5 standardized operative training has received renewed interest for quality assurance in health care.6
However, hand surgery competency training remains challenging for plastic surgery residency programs.7 Importantly, plastic surgery has struggled to train future hand surgeons. The etiology for this likely spans inadequate exposure to hand surgery cases during residency and less desirable case mix among plastic surgeons.7 Furthermore, after a decade of training, plastic surgery residency graduates may be less willing to pursue an additional year of fellowship training.8
Currently, 2 models coexist for plastic surgery training in the United States. The integrated residency model emerged in the 1960s as an alternative to the traditional independent plastic surgery fellowship model. Under the integrated model, a plastic surgery resident receives 6 years of training under the supervision of a plastic surgery residency program director.9 In contrast, the independent model requires 3 years of fellowship training under the program director after completion of a surgical residency program. A third pathway, the combined model, emerged concurrently with the integrated pathway, which is now defunct. The combined model was similar to the independent model in that both required 3 years of plastic surgery training after completion of general surgery training.
This study analyzes national operative case logs of graduating chief residents in U.S. plastic surgery residency programs over a 5-year period. Given the heterogeneity of plastic surgery training in the United States, we hypothesized that significant variability would exist in resident operative hand experience. In addition, given the importance of case minimums for graduation, we hypothesized most residents would achieve hand surgery case minimums. Ultimately, this study may highlight areas to improve the operative experience of plastic surgery residents in hand surgery.
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Methods
After obtaining approval from the institutional review board, national operative case logs for graduating plastic surgery residents were analyzed (2011-2015). The ACGME collects self-reported operative data from residents and summarizes statistics for procedure categories on a national aggregate.10 The following hand surgery procedure categories were analyzed: reconstruction, congenital deformity, tendon (extensor or flexor), nerve, fracture repair, arthroplasty/arthrodesis, amputation,
Results
Cumulative operative case logs were available for 818 plastic surgery residents of 5 consecutive graduating classes (Table 2). A minority of residents were in the integrated pathway (n = 292, 35.7%) relative to the independent/combined pathway (n = 526, 64.3%).
Fold differences between the 10th and 90th percentiles of residents were calculated for hand procedure categories. For every year studied, reconstruction with skin graft and reconstruction with flap had variability less than 10-fold (Fig.
Discussion
Hand surgery training is accomplished through varying degrees of operative experience at U.S. plastic surgery residency programs. In support of our hypothesis, significant variation existed within training models, exceeding a 10-fold threshold during several years. However, variability in operative hand experience decreased over time. By 2015, fold differences between the bottom 10th and top 90th percentiles of residents were less than 10-fold except for reconstruction with flap among
Conclusions
Disparities in operative hand experience during plastic surgery residency may affect surgical competency. Variability decreased over time, but some significant disparities persisted. Future studies are needed to establish evidence-based recommendations for meaningful case minimums. Ultimately, these data may better inform discussions to optimize hand surgery training during plastic surgery residency in the United States.
Financial Disclosure
None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.
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Institutional Review Board: This study was qualified as non-human research and was reviewed by the IRB.