Emergency Surgical Service Enhances Resident Education

LAKE BUENA VISTA, FLA.  – An emergency surgical service rotation delivers more than half of ACGME requirements for laparoscopic surgery in just 2 months of training, a retrospective analysis shows.

"Emergency surgery has the potential to reduce the need for hospital hopping and will increase the time residents spend under their program director," Dr. Hesham Ahmed said at the annual meeting of the Eastern Association for the Surgery of Trauma.

His analysis compared ACGME (Accreditation Council for Graduate Medical Education) requirements before and after the creation of an ESS (emergency surgical service) at Robert Wood Johnson University Hospital in New Brunswick, N.J. Case loads were tabulated for the last four graduating classes (two pre-ESS and two post-ESS) using the hospital’s prospectively accrued ESS database.

More than 70 different types of procedures were recorded in the ESS registry, including multispecialty approaches, reoperations, delayed abdominal closures, urgent surgical airway management, and seldom performed operations such as vagotomy and repair of perforated peptic ulcers.

Residents rotating on the ESS completed 816 cases between 2010 and 2011, 39% of which were laparoscopic, said Dr. Ahmed, a trauma and critical care surgeon at the hospital. This included 109 laparoscopic appendectomies, 99 laparoscopic cholecystectomies, and 14 advanced laparoscopic cases.

ESS significantly increased the total number of laparoscopic appendectomy cases performed by residents compared with the pre-ESS classes of 2008 and 2009 (P value less than .001).

Similar results were found for laparoscopic cholecystectomy cases (P less than .003), notably without a significant increase in conversion to open cholecystectomy (P less than .09), he said.

Within a 2-month period, residents that rotated on the ESS achieved on average 61% of the 60 ACGME required cases for laparoscopy.

ESS faculty supervised 24% of all chief resident major operative and endoscopy cases performed at the academic hospital for the class of 2011.

ESS also increased the total surgical volume at the institution from an almost even split with its participating sites during the two pre-ESS graduating classes of 48% and 50% to 63% and 68% during the two post-ESS graduating classes, Dr. Ahmed said. The increase in volume was statistically significant (P less than .001).

Invited discussant Dr. Jeannette Capella, a surgeon with the department of emergency medicine and trauma service at Altoona (Pa.) Regional Medical Center, said there are numerous financial and practical advantages to including emergency general surgery under the acute care surgery umbrella.

"However, in the struggle to make our specialty financially secure and professionally appealing, we need to make sure that the education of our general surgery residents does not suffer," she said. "To my knowledge, this is the first study to look at how our new practice model is affecting our residents."

Dr. Capella agreed with Dr. Ahmed that shifting residents from affiliated hospital rotations to the ESS at the primary institution would improve residents’ education, but said specific measures such as improved board scores or patient outcomes are needed to demonstrate the quality of education during such a shift.

Anecdotally, Dr. Ahmed said that in the last 2 years, three students went on to critical care or acute care fellowships and that previously "everyone wanted to go to plastic surgery. So there is a big change in the residents."

Dr. Capella then asked how residents’ exposure to other areas of general surgery had been affected and whether the increased workload posed any problems for the hospital in complying with resident work-hour rules. Dr. Ahmed said that no deficiencies arose in the residents’ exposure to other surgical areas, nor were problems encountered with work hours.

Finally, audience members questioned where the cases came from that were filtered to the new ESS. Dr. Ahmed said that they did not do outreach and that prior to the development of the ESS, trauma surgeons would perform the acute care procedures now handled by the ESS.

Dr. Ahmed and his coauthors reported no conflicts of interest.

LAKE BUENA VISTA, FLA.  – An emergency surgical service rotation delivers more than half of ACGME requirements for laparoscopic surgery in just 2 months of training, a retrospective analysis shows.

"Emergency surgery has the potential to reduce the need for hospital hopping and will increase the time residents spend under their program director," Dr. Hesham Ahmed said at the annual meeting of the Eastern Association for the Surgery of Trauma.

His analysis compared ACGME (Accreditation Council for Graduate Medical Education) requirements before and after the creation of an ESS (emergency surgical service) at Robert Wood Johnson University Hospital in New Brunswick, N.J. Case loads were tabulated for the last four graduating classes (two pre-ESS and two post-ESS) using the hospital’s prospectively accrued ESS database.

More than 70 different types of procedures were recorded in the ESS registry, including multispecialty approaches, reoperations, delayed abdominal closures, urgent surgical airway management, and seldom performed operations such as vagotomy and repair of perforated peptic ulcers.

Residents rotating on the ESS completed 816 cases between 2010 and 2011, 39% of which were laparoscopic, said Dr. Ahmed, a trauma and critical care surgeon at the hospital. This included 109 laparoscopic appendectomies, 99 laparoscopic cholecystectomies, and 14 advanced laparoscopic cases.

ESS significantly increased the total number of laparoscopic appendectomy cases performed by residents compared with the pre-ESS classes of 2008 and 2009 (P value less than .001).

Similar results were found for laparoscopic cholecystectomy cases (P less than .003), notably without a significant increase in conversion to open cholecystectomy (P less than .09), he said.

Within a 2-month period, residents that rotated on the ESS achieved on average 61% of the 60 ACGME required cases for laparoscopy.

ESS faculty supervised 24% of all chief resident major operative and endoscopy cases performed at the academic hospital for the class of 2011.

ESS also increased the total surgical volume at the institution from an almost even split with its participating sites during the two pre-ESS graduating classes of 48% and 50% to 63% and 68% during the two post-ESS graduating classes, Dr. Ahmed said. The increase in volume was statistically significant (P less than .001).

Invited discussant Dr. Jeannette Capella, a surgeon with the department of emergency medicine and trauma service at Altoona (Pa.) Regional Medical Center, said there are numerous financial and practical advantages to including emergency general surgery under the acute care surgery umbrella.

"However, in the struggle to make our specialty financially secure and professionally appealing, we need to make sure that the education of our general surgery residents does not suffer," she said. "To my knowledge, this is the first study to look at how our new practice model is affecting our residents."

Dr. Capella agreed with Dr. Ahmed that shifting residents from affiliated hospital rotations to the ESS at the primary institution would improve residents’ education, but said specific measures such as improved board scores or patient outcomes are needed to demonstrate the quality of education during such a shift.

Anecdotally, Dr. Ahmed said that in the last 2 years, three students went on to critical care or acute care fellowships and that previously "everyone wanted to go to plastic surgery. So there is a big change in the residents."

Dr. Capella then asked how residents’ exposure to other areas of general surgery had been affected and whether the increased workload posed any problems for the hospital in complying with resident work-hour rules. Dr. Ahmed said that no deficiencies arose in the residents’ exposure to other surgical areas, nor were problems encountered with work hours.

Finally, audience members questioned where the cases came from that were filtered to the new ESS. Dr. Ahmed said that they did not do outreach and that prior to the development of the ESS, trauma surgeons would perform the acute care procedures now handled by the ESS.

Dr. Ahmed and his coauthors reported no conflicts of interest.

LAKE BUENA VISTA, FLA.  – An emergency surgical service rotation delivers more than half of ACGME requirements for laparoscopic surgery in just 2 months of training, a retrospective analysis shows.

"Emergency surgery has the potential to reduce the need for hospital hopping and will increase the time residents spend under their program director," Dr. Hesham Ahmed said at the annual meeting of the Eastern Association for the Surgery of Trauma.

His analysis compared ACGME (Accreditation Council for Graduate Medical Education) requirements before and after the creation of an ESS (emergency surgical service) at Robert Wood Johnson University Hospital in New Brunswick, N.J. Case loads were tabulated for the last four graduating classes (two pre-ESS and two post-ESS) using the hospital’s prospectively accrued ESS database.

More than 70 different types of procedures were recorded in the ESS registry, including multispecialty approaches, reoperations, delayed abdominal closures, urgent surgical airway management, and seldom performed operations such as vagotomy and repair of perforated peptic ulcers.

Residents rotating on the ESS completed 816 cases between 2010 and 2011, 39% of which were laparoscopic, said Dr. Ahmed, a trauma and critical care surgeon at the hospital. This included 109 laparoscopic appendectomies, 99 laparoscopic cholecystectomies, and 14 advanced laparoscopic cases.

ESS significantly increased the total number of laparoscopic appendectomy cases performed by residents compared with the pre-ESS classes of 2008 and 2009 (P value less than .001).

Similar results were found for laparoscopic cholecystectomy cases (P less than .003), notably without a significant increase in conversion to open cholecystectomy (P less than .09), he said.

Within a 2-month period, residents that rotated on the ESS achieved on average 61% of the 60 ACGME required cases for laparoscopy.

ESS faculty supervised 24% of all chief resident major operative and endoscopy cases performed at the academic hospital for the class of 2011.

ESS also increased the total surgical volume at the institution from an almost even split with its participating sites during the two pre-ESS graduating classes of 48% and 50% to 63% and 68% during the two post-ESS graduating classes, Dr. Ahmed said. The increase in volume was statistically significant (P less than .001).

Invited discussant Dr. Jeannette Capella, a surgeon with the department of emergency medicine and trauma service at Altoona (Pa.) Regional Medical Center, said there are numerous financial and practical advantages to including emergency general surgery under the acute care surgery umbrella.

"However, in the struggle to make our specialty financially secure and professionally appealing, we need to make sure that the education of our general surgery residents does not suffer," she said. "To my knowledge, this is the first study to look at how our new practice model is affecting our residents."

Dr. Capella agreed with Dr. Ahmed that shifting residents from affiliated hospital rotations to the ESS at the primary institution would improve residents’ education, but said specific measures such as improved board scores or patient outcomes are needed to demonstrate the quality of education during such a shift.

Anecdotally, Dr. Ahmed said that in the last 2 years, three students went on to critical care or acute care fellowships and that previously "everyone wanted to go to plastic surgery. So there is a big change in the residents."

Dr. Capella then asked how residents’ exposure to other areas of general surgery had been affected and whether the increased workload posed any problems for the hospital in complying with resident work-hour rules. Dr. Ahmed said that no deficiencies arose in the residents’ exposure to other surgical areas, nor were problems encountered with work hours.

Finally, audience members questioned where the cases came from that were filtered to the new ESS. Dr. Ahmed said that they did not do outreach and that prior to the development of the ESS, trauma surgeons would perform the acute care procedures now handled by the ESS.

Dr. Ahmed and his coauthors reported no conflicts of interest.