Transcript Document

Advanced Laparoscopic
Fellowship and General Surgery
Residency can Co-exist without
Detracting from Surgical Resident
Operative Experience
Shanu N. Kothari, M.D., F.A.C.S.
Thomas H. Cogbill, M.D., F.A.C.S.
Colette T. O’Heron
Michelle A. Mathiason, M.S.
Surgical Endoscopy (2001) 15:1066-1070.
Rattner DW, et al.
• 47% of residents felt that additional
training was necessary to perform
advanced laparoscopic procedures
Surgical Endoscopy (2001) 15:1066-1070.
Rattner DW, et al.
• 47% of residents felt that additional
training was necessary to perform
advanced laparoscopic procedures
• 65% of respondents would pursue an
additional year of advanced laparoscopic
training if it were available
Surgical Endoscopy (2001) 15:1066-1070.
# of MIS Fellowships*
•
•
•
•
•
1993:
2004:
2005:
2006:
2007:
<10 programs
80 programs
91 programs
108 programs
127 programs
* National Resident Matching Program. Results and Data. Specialties
Matching Service 2008 Appointment Year. NRMP, February 2008
•
•
•
•
•
1993:
2004:
2005:
2006:
2007:
<10 programs
80 programs
91 programs
108 programs
127 programs
Surgeries
# of MIS Fellowships* # of Bariatric Procedures
180,000
180,000
160,000
160,000
140,000
140,000
120,000
120,000
100,000
100,000
80,000
80,000
60,000
60,000
40,000
40,000
20,000
20,000
-
2001
2002
2003
* National Resident Matching Program. Results and Data. Specialties
Matching Service 2008 Appointment Year. NRMP, February 2008
2004
2005
The Concern
More Advanced
Laparoscopic Fellows
Competing for Cases
Residents Graduating
with Suboptimal
Advanced Laparoscopic
Case Load
More Advanced
Laparoscopic Fellowships
Objective
• To evaluate the impact of adding an
advanced laparoscopic fellowship on
general surgery residency case
volume at our institution
Gundersen Lutheran
• 325 bed community-based teaching
hospital
• ACGME–accredited general surgery
residency since 1974
• 2 chief residents each year
Gundersen Lutheran
• August 2001, established a minimally
invasive clinical bariatric surgery
program
• In July 2003, initiated minimally
invasive bariatric/advanced
laparoscopic fellowship
Four Surgical Services
•
•
•
•
Vascular
Trauma
Endocrine/oncology
Minimally Invasive Surgery/Bariatric
Four Surgical Services
– Ideally, there is a junior and senior resident assigned to
each service
– All chief residents spend three months on each service
– The only MIS case exclusively performed by fellows is
laparoscopic gastric bypasses
– Fellows are allowed to perform non-bariatric advanced
laparoscopic cases if the complexity of the procedure is
beyond the skill level of a resident on the service, as
determined by the attending surgeon, or the case is
uncovered. Otherwise, all advanced laparoscopic cases are
performed with the resident as “surgeon” and the attending
or fellow as “teaching assistant”
Initiation of
Laparoscopic Fellowship
Program
Resident Laparoscopic
Case Load
2000
Resident + Fellow
Laparoscopic Case Load
2004
2007
Statistical Analysis
• T-test was used to compare pre
fellowship to post fellowship case
numbers
• Statistical significance was defined as
p<0.05
Fellows’ Experience
Fellow
Graduate
Year
Basic
Laparoscopic
Advanced
Laparoscopic
Non-Bariatric
Advanced
Laparoscopic
Bariatric
Total
2004
31
40
106
177
2005
42
76
100
218
2006
50
66
113
229
2007
30
85
83
198
Resident Case Volume Pre/Post-Fellowship
250
Basic Cases
225
200
Mean # Cases
175
150
125
100
140.5 ± 19.4
75
50
25
0
Pre-Fellowship
Resident Case Volume Pre/Post-Fellowship
250
Basic Cases*
225
200
Mean # Cases
175
150
125
100
140.5 ± 19.4
193.3 ± 34.5
Pre-Fellowship
Post-Fellowship
75
50
25
0
* P=0.003
Resident Case Volume Pre/Post-Fellowship
250
Basic Cases*
225
Advanced Cases**
200
Mean # Cases
175
150
125
100
140.5 ± 19.4
193.3 ± 34.5
75
50
77 ± 17.8
25
0
Pre-Fellowship
* P=0.003
Post-Fellowship
Resident Case Volume Pre/Post-Fellowship
250
Basic Cases*
Advanced Cases**
225
200
Mean # Cases
175
150
125
100
140.5 ± 19.4
193.3 ± 34.5
75
50
77 ± 17.8
113.3 ± 23.5
25
0
Pre-Fellowship
* P=0.003; **P=0.005
Post-Fellowship
All Non-Bariatric Laparoscopic Cases per
Surgeon during Graduating Year
140
120
100
80
N
60
40
20
0
1999
2000
2001
2002
2003
Year
Chief Residents
2004
2005
2006
All Non-Bariatric Laparoscopic Cases per
Surgeon during Graduating Year
140
120
100
80
N
60
40
20
0
1999
2000
2001
2002
2003
2004
2005
Year
Chief Residents
Fellows*
*In addition to these laparoscopic cases, fellows performed a mean
of 101 laparoscopic bariatric cases during their fellowship year.
2006
Laparoscopic Inguinal Herniorrhaphy
40
35
30
25
N 20
15
10
5
0
2000
2001
2002
2003
2004
Year
National Average SJ + SC
2005
2006
2007
Laparoscopic Inguinal Herniorrhaphy
40
35
30
25
N 20
15
10
5
0
2000
2001
2002
2003
2004
2005
2006
Year
GL Average SJ + SC
National Average SJ + SC
2007
Laparoscopic Inguinal Herniorrhaphy
40
35
30
25
N 20
15
10
5
0
2000
2001
2002
2003
2004
2005
2006
Year
GL Fellow
GL Average SJ + SC
National Average SJ + SC
2007
Laparoscopic Antireflux Surgery
40
35
30
25
N 20
15
10
5
0
2000
2001
2002
2003
2004
Year
National Average SJ + SC
2005
2006
2007
Laparoscopic Antireflux Surgery
40
35
30
25
N 20
15
10
5
0
2000
2001
2002
2003
2004
2005
2006
Year
GL Average SJ + SC
National Average SJ + SC
2007
Laparoscopic Antireflux Surgery
40
35
30
25
N 20
15
10
5
0
2000
2001
2002
2003
2004
2005
2006
Year
GL Fellow
GL Average SJ + SC
National Average SJ + SC
2007
Laparoscopic Partial Colectomy
40
35
30
25
N 20
15
10
5
0
2000
2001
2002
2003
2004
Year
National Average SJ + SC
2005
2006
2007
Laparoscopic Partial Colectomy
40
35
30
25
N 20
15
10
5
0
2000
2001
2002
2003
2004
2005
2006
Year
GL Average SJ + SC
National Average SJ + SC
2007
Laparoscopic Partial Colectomy
40
35
30
25
N 20
15
10
5
0
2000
2001
2002
2003
2004
2005
2006
Year
GL Fellow
GL Average SJ + SC
National Average SJ + SC
2007
Discussion
Discussion
• A high volume of basic and advanced laparoscopic
procedures should be performed at the sponsoring
institution to limit competition for those cases by residents
and fellows
Discussion
• A high volume of basic and advanced laparoscopic
procedures should be performed at the sponsoring
institution to limit competition for those cases by residents
and fellows
• Clear cut ground rules need to be established and followed
– who is assigned to be surgeon, under what circumstances,
and who is primarily responsible for perioperative
management of each patient
Discussion
• A high volume of basic and advanced laparoscopic
procedures should be performed at the sponsoring
institution to limit competition for those cases by residents
and fellows
• Clear cut ground rules need to be established and followed
– who is assigned to be surgeon, under what circumstances,
and who is primarily responsible for perioperative
management of each patient
• Open communication and excellent working relationship
between residency director and fellowship director is
essential
Limitations
Limitations
• Our general surgery program is small, and the lack of a
chief resident on the MIS service for 6 months of the year
may positively affect our fellows’ operating experience and
may not be applicable to large surgery programs that
always have a chief resident on service
Limitations
• Our general surgery program is small, and the lack of a
chief resident on the MIS service for 6 months of the year
may positively affect our fellows’ operating experience and
may not be applicable to large surgery programs that
always have a chief resident on service
• Several MIS fellowships have more than one fellow present
and this may dilute the exposure of a defined set of
advanced MIS cases amongst residents and fellows even
further
Limitations
• Our general surgery program is small, and the lack of a
chief resident on the MIS service for 6 months of the year
may positively affect our fellows’ operating experience and
may not be applicable to large surgery programs that
always have a chief resident on service
• Several MIS fellowships have more than one fellow present
and this may dilute the exposure of a defined set of
advanced MIS cases amongst residents and fellows even
further
• The fellowship director makes it very clear that they cannot
“steal” cases from the surgery residents; rather acting as a
teaching assistant, unless the case is uncovered. As a result,
our data may not be comparable to programs that do not
have similar “ground rules” for the resident–fellow
interactions
Conclusion
• General surgery resident experience
with basic and non-bariatric
advanced laparoscopic cases did not
decrease with the addition of an
advanced laparoscopic fellowship
Conclusion
• General surgery resident experience
with basic and non-bariatric
advanced laparoscopic cases did not
decrease with the addition of an
advanced laparoscopic fellowship
• Residents’ operative case volume
during their chief year was not
negatively impacted
Conclusion
• As a result of the cooperative efforts of the
fellowship and residency directors as well
as an expansion of the total number of
laparoscopic cases performed at our
institution due to changes in clinical
practice, surgery residents reported an
increase in the number of laparoscopic
cases while a successful fellowship was
established