Alignment of Training Curriculum and Surgical Practice: Implications for Competency, Manpower, and Practice Modeling

Abstract

Objective The attractiveness of pediatric surgery (PS) as a specialty includes its primary role in the care of multisystemic disease. We were interested in identifying changes in operative case quality and quantity when comparing PS residents to PS practitioners.

Methods The 2006 Accreditation Council for Graduate Medical Education PS resident current procedural terminology (CPT) code database (26,077 resident cases) was merged with the 2006 Kids' Inpatient Database of International Classification of Diseases (ICD)-9 procedure codes (230,504 practitioner cases) and categorized by case type and volumes according to a resident CPT reference file. Cases were categorized into 84 procedure types. A recent estimate of 691 practicing pediatric surgeons was used as denominator to calculate case volume per surgeon. Our analysis focused on the PS index cases and we compared PS residents to subspecialty board certified general pediatric surgeons in practice. We excluded cases that may be performed by general surgeons without PS training.

Results Our data indicate that, on average, 501 cases are performed annually by each PS resident. We identified significant differences in case volume per surgeon between training and practice for most PS index cases.

Conclusions The PS index case quantity declined significantly from training to practice. If a volume to outcome relationship applies to these complex and infrequent PS cases, then to sustain and improve clinical quality post-training will require a new paradigm of continued learning. Additionally, a relook at the optimal manpower and more focused regionalization is warranted.

Keywords

pediatric surgery training - surgical volume - competency

• References

• 1 Ziegler MM. The history of pediatric surgery in the United States. In: Ziegler MM, Azizkhan RG, Weber TR, , eds. Operative Pediatric Surgery. New York, NY: McGraw-Hill Co.; 2003: 3-11
• 2 Available at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/445_pediatric_surgery_07012007_u08102008.pdf
• 3 Available at: http://www.acgme.org/acWebsite/RRC_440/440_pedMinNumbers.pdf
• 4 Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003; 349 (22) 2117-2127
• 5 Birkmeyer JD, Siewers AE, Finlayson EV , et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346 (15) 1128-1137
• 6 Hannan EL, Racz M, Kavey RE, Quaegebeur JM, Williams R. Pediatric cardiac surgery: the effect of hospital and surgeon volume on in-hospital mortality. Pediatrics 1998; 101 (6) 963-969
• 7 Available at: http://www.hcup-us.ahrq.gov/kidoverview.jsp
• 8 Pediatric Surgical Resident Case Log. Available at: www.acgme.org
• 9 Poley S, Ricketts T, Belsky D, Gaul K. Pediatric surgeons: subspecialists increase faster than generalists. Bull Am Coll Surg 2010; 95 (10) 35-38
• 10 Abdullah F, Gabre-Kidan A, Zhang Y, Sharpe L, Chang DC. Report of 2,087,915 surgical admissions in U.S. children: inpatient mortality rates by procedure and specialty. World J Surg 2009; 33 (12) 2714-2721
• 11 Massarweh NN, Flum DR, Symons RG, Varghese TK, Pellegrini CA. A critical evaluation of the impact of Leapfrog's evidence-based hospital referral. J Am Coll Surg 2011; 212 (2) 150-159.e1
• 12 Available at: http://home.absurgery.org/default.jsp?exam-moc
• 13 Raval MV, Dillon PW, Bruny JL , et al; ACS NSQIP Pediatric Steering Committee. American College of Surgeons National Surgical Quality Improvement Program Pediatric: a phase 1 report. J Am Coll Surg 2011; 212 (1) 1-11