Elsevier

Journal of Surgical Education

Volume 74, Issue 4, July–August 2017, Pages 650-655
Journal of Surgical Education

Original Reports
Variable Operative Experience in Hand Surgery for Plastic Surgery Residents

https://doi.org/10.1016/j.jsurg.2016.12.001Get rights and content

Background

Efforts to standardize hand surgery training during plastic surgery residency remain challenging. We analyze the variability of operative hand experience at U.S. plastic surgery residency programs.

Methods

Operative case logs of chief residents in accredited U.S. plastic surgery residency programs were analyzed (2011-2015). Trends in fold differences of hand surgery case volume between the 10th and 90th percentiles of residents were assessed graphically. Percentile data were used to calculate the number of residents achieving case minimums in hand surgery for 2015.

Results

Case logs from 818 plastic surgery residents were analyzed of which a minority were from integrated (35.7%) versus independent/combined (64.3%) residents. Trend analysis of fold differences in case volume demonstrated decreasing variability among procedure categories over time. By 2015, fold differences for hand reconstruction, tendon cases, nerve cases, arthroplasty/arthrodesis, amputation, arterial repair, Dupuytren release, and neoplasm cases were below 10-fold. Congenital deformity cases among independent/combined residents was the sole category that exceeded 10-fold by 2015. Percentile data suggested that approximately 10% of independent/combined residents did not meet case minimums for arterial repair and congenital deformity in 2015.

Conclusions

Variable operative experience during plastic surgery residency may limit adequate exposure to hand surgery for certain residents. Future studies should establish empiric case minimums for plastic surgery residents to ensure hand surgery competency upon graduation.

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.

Section snippets

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.

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