The ACGME (Accreditation Council for Graduate Medical Education) is the private, non-profit council that evaluates and accredits medical residency programs in the United States. Surgical residents are required to complete certain numbers of cases during residency and each case is logged by the resident at the ACGME website. Currently, I am doing an endoscopy rotation and my concern, in addition to the joy of learning, is performing enough EGD’s (esophagogastricduodenoscopy) and colonoscopies to meet the requirements.
The question of my week is, “So, how many cases have you done?” This is often asked by other residents and faculty. Faculty are usually trying to confirm that the resident’s time on a rotation is bearing fruit in the form of measurable training opportunities. The intra-resident discussion, however, has many angles. Frequently the conversation turns into a series of “fish stories” to see who holds the record. This week my numbers were not high enough to satisfy a senior resident, so I had to hear about that. This prompted an interesting discussion.
I log cases in which my hands come into contact with the patient and some instrument to perform a procedure. If I only watch the endoscopy, I don’t log it – same as if I only watch a surgery. It is true that watching and imagining procedures does improve motor skills, but I am not convinced that those activities should be part of the case log. There is a higher level of skill development when “doing” and the ACGME is measuring “doing”.
Not all residents see it that way. To some, if they watch a scope, they were there learning, so they log the case. There is a concern with having enough numbers to provide documentation of adequate training for attaining hospital privileges and some feel that only logging cases “performed” will not document the full extent of their training in this area. The rationale: more thorough documentation demonstrating the depth of excellent training – seeing and doing.
On the other and, it is my belief that the ACGME set the case numbers with the knowledge that seeing procedures will occur as part of the process. Otherwise, what does completion of an accredited surgical residency mean if meeting the case goals implies a questionable or inadequate level of training, but further documentation of watched cases dispels that?
I am concerned that an attempt to log watched cases amounts to grade inflation and residents may be under peer-pressure to “keep up with the Jones” – no one wants to have the program director take an interest in their “low” case numbers compared to their peers.
When filling out the log, the resident is asked to identify his/her role. There is no role of “Observer”. The choices are: “Surgeon Chief” exclusively for cases logged during the chief year, “Surgeon JR” for cases logged as the primary operating resident, “1st Assistant” for residents who helped (the case thus logged doesn’t count towards numbers, but is captured to show hands-on skill development), and “Teaching Assistant” for senior residents who take junior residents through a case while the attending watched or assisted.
Under which role should I log observed cases, if I were to begin that habit? I don’t think they good enough for Surgeon JR. But what if they are?
The esteemed Jonathan Swift School of Medicine might advocate a new model for surgical education. They could announce the great day of telemedicine for surgical residents has arrived! Stay home and watch these videos, then take this test, and the diploma will be in the mail.
My program has a virtual reality colonoscopy trainer. I could log those cases vs. the ones I watched on an HD video screen because, at least, I DID something. Isn’t that somewhere between watching a scope and doing a “live” scope? Should I log a laproscopic case the next time I catch one on Discovery Health?
Adding further stress to the system, this year the ACGME increased the number of required endoscopies, among other cases. Of course, the work hours to accomplish more cases remained the same. There is much discussion in Surgery about the work hour restriction; the ACGME is very concerned with surveillance to prevent residents from working 80+ and deflating their logged hours to “comply”. I don’t hear much concern that the other side of the equation may be equally susceptible to manipulation – case inflation.
Mathematically: Cases/Work hours = Educational Efficiency. If one is able to reduce work hours and maintain case numbers, presumably menial tasks are eliminated and residents use the time bonus to study, feel more cheerful, and see their families. Win-win. Educational efficiency and quality of life increase. Unfortunately, there are limits and this single equation’s view from 30,000′ is a crude estimate of reality. Still, if work hours are locked to provide a more equitable living situation for residents, the only way to improve educational efficiency is to increase cases numbers. Do more with less.
Doing more with less tempts the inner capitalist and we may strive to wring ever more efficiency out of the system, but at what cost? There has to be a cost to this kind of thinking, otherwise we wouldn’t be in our present economic catastrophe and NASA, too, might have avoided a crash (Mars Orbiter).
The efficiency equation only looks at one part because it assumes a case is a case is a case. Once all the unnecessary tasks are eliminated to make room for more cases, something has to give, if, yet, more cases are to be counted. Case inflation necessarily decreases case quality in order to provide further “efficiency” in this equation. The pursuit of efficiency above all else risks the “Wal-Mart-ization” of surgical education, namely, bottom-tier, high quantity product. Where is the balance?
I think the sober-minded person keeps the ideas of retained quality and fairness in tension with promises of greater efficiency. Henry Ford put it this way:
“There is one rule for industrialists and that is: make the best quality of goods possible at the lowest cost possible, paying the highest wages possible.“
Certainly Wal-Mart, our present economic troubles, and case inflation all fall short of this ideal balance of quality, fairness, and efficiency.
Each time I log my cases the Website prompts me to “Please select a value” for the field of “Residents Role”. I consider my role and carefully choose the correct value. I probably won’t break any records for most cases, but…
“If gold rust, what shall poor iron do?” – Chaucer
Please select a value
