See None, Do Some, Teach None: An Analysis of the Contemporary Operative Experience as Nonprimary Surgeon

Abstract

Objective: The operative experience of today's general surgery resident has changed, but little is known about the modern experience as nonprimary surgeon. We set out to explore changes in the operative experience of general surgery residents as first assistant (FA) and teaching assistant (TA).

Design, setting, and participants: This is a review of ACGME national operative log reports from 1990 to 2018. TA and FA cases were analyzed. Statistical analysis was performed using polynomial regression analysis and Kruskal-Wallis test. Statistical significance was set at p < 0.05.

Results: 30,260 individuals completed general surgery residency during the study period with medians of 951 (interquartile range: 929-974) total major, 63 (31-184) FA, and 32 (25-48) TA cases. As a proportion of total cases completed, FA cases decreased from 21.8% of the total operative experience in 1990 to 2.5% in 2018, and TA cases declined from 7.4% of the total operative experience in 1990 to 3.5% in 2018. Regression modeling demonstrated that both operative roles decreased over time, but at a progressively decreasing rate, with FA cases reaching a "floor" around 2010 and TA cases reaching a "breakpoint" in 2008 at which time operative volume rebounded and began to increase. Among the core general surgery domains of abdomen and alimentary tract, compositional analysis revealed a decrease across each of the 11 operative subcategories (all p < 0.05) for FA, and for TA, a decrease in 6 of the 11 operative subcategories (stomach, small intestine, large intestine, anorectal, hernia, and biliary, all p < 0.05).

Conclusions: Over the past 3 decades, the resident operative experience as nonprimary surgeon has decreased dramatically, with today's residents graduating with fewer FA and TA cases. As surgical training has traditionally relied heavily on an apprenticeship model for learning technical skills, it is essential that surgical educators recognize and rectify these trends.

Keywords: ACGME; Medical Knowledge; Patient Care; Practice-Based Learning and Improvement; case logs; first assistant; operative volume; surgical education; teaching assistant.