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The ups and downs of general surgery resident experience in endocrine surgery: Analysis of 30 years of ACGME graduate case logs

Published:August 16, 2020DOI:https://doi.org/10.1016/j.surg.2020.07.007

      ABSTRACT

      Background

      The aim of this study was to determine trends in the experience of general surgery residents with endocrine surgery cases.

      Methods

      American Association of Endocrine Surgeons national general surgery case logs from 1989 through 2019 were reviewed. The numbers of individuals completing residency and the mean and median number of endocrine surgery cases by type and by level of operating resident surgeon were abstracted from annual data and analyzed. Descriptive statistics and linear regression analyses were performed modeling endocrine surgery cases over time and stratified by procedure type and resident level.

      Results

      The number of individuals completing general surgery residency each year increased from 981 to 1,219 (P < .001). The average total number of endocrine surgery cases performed increased from 17 to 33.2 (P < .001) but has declined since its peak at 36.9 in 2010 to 2011 (P = .014). Thyroid operations increased from 11.4 to 19.8 (P < .001) but peaked at 23.5 in 2010 to 2011 and have since declined (P < .001). Parathyroid operations more than doubled from 4.2 to 9.7 (P < .001). Adrenal operations increased from 1 to 2.2 (P < .001) and pancreatic endocrine operations increased from 0.2 to 1.5 (P < .001). Surgeon Chief endocrine surgery cases peaked at 14.4 in 2003 to 2004 but have since declined by 22.2% (P < .001). Surgeon Junior endocrine surgery cases increased overall (P < .001) but peaked at 22.8 in 2011 to 2012. There was increasing heterogeneity over time in trainee experience (P < .001).

      Conclusion

      After having increased for 2 decades, the number of endocrine surgery cases performed by general surgery residents is currently in decline. Possible contributing factors include growth in the number of general surgery residents, variable and narrowed case mix, and encroachment by other learners.

      Introduction

      The number of endocrine surgery cases (ESCs) performed in the United States has increased steadily during the past 2 decades with a projected 103,704 procedures in 2020.
      • Sosa J.A.
      • Wang T.S.
      • Yeo H.L.
      • et al.
      The maturation of a specialty: workforce projections for endocrine surgery.
      ,
      • Abdulla A.G.
      • Ituarte P.H.G.
      • Harari A.
      • Wu J.X.
      • Yeh M.W.
      Trends in the frequency and quality of parathyroid surgery: analysis of 17,082 cases over 10 years.
      In the United States, low-volume general surgeons continue to perform the majority of ESCs.
      • Kuo J.H.
      • Pasieka J.L.
      • Parrack K.M.
      • Chabot J.A.
      • Lee J.A.
      Endocrine surgery in present-day academia.
      A review of 16,954 total thyroidectomies from 1998 to 2009 found that of surgeons performing total thyroidectomy, 51% performed 1 case per year with a median of 7 cases per year.
      • Adam M.A.
      • Thomas S.
      • Youngwirth L.
      • et al.
      Is there a minimum number of thyroidectomies a surgeon should perform to optimize patient outcomes?.
      This is changing after the creation of the American Association of Endocrine Surgeons (AAES) and development of formal Endocrine Surgery fellowship training programs with higher rates of endocrine procedures now performed by high volume surgeons.
      • Chen H.A.
      • Krishnamurthy V.D.
      • Siperstein A.
      • Carty S.
      • Chen H.
      Four decades of the American Association of Endocrine Surgeons (AAES): past, present, and future.
      However, workforce projections suggest that the volume of endocrine surgical disease will outpace the number of AAES trained surgeons, emphasizing the importance of early exposure, mentoring, and competency building in ESCs during general surgery (GS) residency.
      • Sosa J.A.
      • Wang T.S.
      • Yeo H.L.
      • et al.
      The maturation of a specialty: workforce projections for endocrine surgery.
      ,
      • Saunders B.D.
      • Wainess R.M.
      • Dimick J.B.
      • Doherty G.M.
      • Upchurch G.R.
      • Gauger P.G.
      Who performs endocrine operations in the United States?.
      Endocrine surgery is 1 of 10 essential content areas of general surgery (GS) training recognized by the Accreditation Council for Graduate Medical Education (ACGME).
      ACGME Surgery Review Committee
      ACGME program requirements for graduate medical education in general surgery.
      Additionally, parathyroidectomy and thyroidectomy, partial and total, are among the 90 essential core procedures listed in the American Board of Surgery’s Surgical Council on Resident Education curriculum for GS residents.
      Surgical Council on Resident Education
      SCORE: 2019-2020 curriculum outline for general surgery.
      In 2018 the ACGME Review Committee for Surgery increased the minimum number of ESCs required per graduate from 8 to 15 cases, with an additional specification that 10 should be thyroid or parathyroid cases.
      ACGME Review Committee for Surgery
      Defined category minimum numbers for general surgery residents and credit role.
      There is a paucity of evidence examining the long-term trends in endocrine surgery volume among GS trainees. Because GS residency is expected to train its graduates to perform all aspects of endocrine surgical care and remains the endpoint for most surgeons performing endocrine procedures, it is important to review trends in this experience over time. Our primary objective was to define the total experience of GS residents with ESCs during a 30-year period (1989−2019). Secondary objectives were to examine the differences in resident operative volume between thyroid, parathyroid, adrenal, and pancreatic neuroendocrine tumors as well as by level of training: junior versus chief residents.

      Methods

      The operative case logs of all graduating GS residents enrolled in ACGME-accredited programs were evaluated for the academic years 1989 to 1990 through the 2018 to 2019 year. The data were derived from publicly available ACGME General Surgery Operative Log system of the Residency Review Committee for Surgery (RRC-Surgery).
      Accreditation Council for Graduate Medical Education
      Accreditation data system: Case log graduate statistics.
      The ACGME Operative Case Log represents a unique and robust database to study trends over time and one that has not been previously analyzed for this purpose. For this retrospective study, the dataset was abstracted and analyzed by a single co-author (J.R.P.). The content, analytical accuracy, and results interpretation is solely the individual responsibility of the authors and not the ACGME RRC-Surgery.
      The number of programs graduating at least one resident and number of graduating chief residents per year was obtained. The number of thyroid procedures, parathyroid procedures, adrenal procedures, and pancreatic neuroendocrine procedures performed were reviewed. The data were stratified into cases performed as a surgeon chief (those cases performed as a chief resident) or as a surgeon junior (cases performed in the surgeon role at any other time in residency). Cases classified as “first assistant” role were not included.
      Descriptive statistics was carried out using analysis of variance tests. Linear regression analyses were performed modeling the mean number of ESCs performed over time and stratified by endocrine procedure type and resident experience. To assess variability in resident operative experience, the mean number of cases performed at the 10th and 90th percentile were calculated during the study period and stratified by experience level. Medians were calculated for endocrine procedures performed over time as well as by procedure type and resident experience level. Both median and mean values were calculated. We found that medians were not significantly different than means. We therefore only presented mean values, both for clarity, and because all the statistical tests used are based on comparisons of means. Statistical analyses were performed using Excel Analysis ToolPak.

      Results

      The number of general surgery programs that have graduated residents decreased from 279 programs in 1989 to 1990 to 249 programs in 2018 to 2019 (P < .001; R2 = 0.85; Δ/year = −1.05) reaching a nadir in 2012 to 2013 of 240 programs. Despite fewer training programs, the number of individuals completing general surgery residency each year increased 24.3% from 981 graduates in 1989 to 1990 to 1219 graduates in 2018 to 2019, respectively (P < .001; R2 = 0.69; Δ/year = +6.76; Fig 1).
      Figure thumbnail gr1
      Fig 1Thirty-year trend from academic year 1989 to 1990 to 2018 to 2019 of general surgery programs that have graduated residents and graduating general surgery residents per year.
      Figure 2 depicts the mean number of ESCs performed over time and endocrine procedure type. During the past 30 years, GS residents increased their average endocrine case volume from a mean of 17 to 33.2 cases or increase of 0.69 cases per year (P < .001) corresponding to an overall increase of 91.9%. Since its peak in 2010 to 2011 of an average of 36.9 cases, the endocrine case volume has declined 10%, or a decrease of 0.40 cases per year (P = .014).
      Figure thumbnail gr2
      Fig 2Mean number of endocrine surgical cases performed from academic year 1989 to 1990 to 2018 to 2019 stratified by endocrine procedure type.
      When stratified by procedure type, it was primarily the increase in the number of cervical endocrine cases (thyroidectomies and parathyroidectomies) that contributed to the rise in ESCs volume. Residents increased their thyroidectomy volume by 73.7% from 11.4 to 19.8, or 0.4 more cases per year (P < .001). This increase peaked at 23.5 cases in 2010 to 2011 and has declined significantly in the intervening decade by 15.7%, or 0.47 cases per year (P < .001). The number of parathyroid procedures more than doubled during the study period but represent a smaller proportion of the endocrine case volume. On average, GS residents saw a 123.8% increase of parathyroidectomies from 4.2 to 9.7, respectively, or an increase of 0.21 cases per year (P < .001). As with thyroidectomies, the parathyroidectomy case volume steadily increased until 2010 to 2011 but unlike thyroidectomies, it has remained stable since then (P = .77).
      Adrenal and pancreatic neuroendocrine procedures performed during GS residency increased overall throughout the study period. Residents today graduate with an average of 2.2 adrenalectomies, up from 1.0 in 1989 representing an increase of 0.04 per year (P < .001). The number of adrenalectomies has remained stagnant since 2007. Pancreatic neuroendocrine procedures also were noted to have increased gradually from an average of 0.2 to 1.5 cases; a change of 0.03 cases per year (P < .001).
      When evaluating the ESC volume by resident level (Fig 3), residents perform more cases as surgeon juniors than as surgeon chiefs. This trend is particular notable for cervical endocrine procedures. This difference in endocrine volume by resident level has continued to widen since the number of cases by surgeon juniors and surgeon chiefs converged in 2002 to 2003. In 2003 to 2004, endocrine operations as Surgeon Chief peaked at 14.4 cases and have since declined by 22.2% to 11.2 cases, a decrease of 0.22 cases per year (P < .001). For surgeon juniors, endocrine procedures steadily increased by 0.76 cases per year through 2011 to 2012, completing on average 22.8 cases (P < .001) without significant change since that time.
      Figure thumbnail gr3
      Fig 3Mean number of endocrine surgical cases performed from academic year 1989 to 1990 to 2018 to 2019 stratified by resident experience level (surgeon junior versus surgeon chief).
      When stratified by type of endocrine procedure (Fig 4, A and B), surgeon juniors are performing more thyroid and parathyroid cases than their chief residents. The chief resident case volume for thyroid and parathyroid cases have remained stagnant for the past 30 years, performing 6.0 thyroidectomies and 3.1 parathyroidectomies in their final year of training (P > .05). Thyroid cases increased to a maximum of 8.5 cases from 2008 to 2009 before steadily decreasing during 1989 to 1990 numbers (P < .001). Similarly, parathyroid cases increased to a maximum of 4.7 cases in 2003 to 2004 before also decreasing to 1989 to 1990 averages (P < .001). In contrast, general surgery junior residents averaged 13.8 thyroidectomies in 2019, compared with 5.1 cases in 1989, and 6.5 parathyroidectomies in 2019, compared with 1.6 cases in 1989 (P < .001, respectively). Thyroid cases performed by surgeon juniors have also seen a similar decrease to those performed by surgeon chiefs after reaching a maximum of 15.4 cases in 2010 to 2011 (P = .002).
      Figure thumbnail gr4
      Fig 4Surgeon junior versus Surgeon Chief endocrine surgical volume from academic year 1989 to 1990 to 2018 to 2019 in cervical endocrine procedures. (A) Thyroidectomy case volume over time. (B) Parathyroidectomy case volume over time.
      In addition to the significant discrepancy in average case volume by resident role, there exists significant variability in the maximum and minimum numbers of ESCs performed by an individual resident. Residents in the 90th percentile of total ESC volume reported 52 cases from 2018 to 2019, compared with 30 cases in 1989 to 1990, while those in the 10th percentile reported 17 cases in 2018 to 2019 compared with 8 cases in 1989 to 1990. During the 30-year study period, the variability in ESC volume performed by GS residents has increased over time from a difference of 22 cases between the 10th and 90th percentile compared with 35 cases, respectively (Fig 5).
      Figure thumbnail gr5
      Fig 5Heterogeneity in Endocrine Surgery case volume of general surgery residents from academic year 1989 to 1990 to 2018 to 2019.
      Figure 6, A and B depicts the reported ESC volume during the study period by surgeon juniors and surgeon chiefs divided into 10th, 30th, 50th, 70th, and 90th percentiles. Although there was variation between the 10th and 90th percentile during the study period, there was no meaningful difference from a training perspective when comparing the first year of the study period to the final year of the study period. The 90th percentile of surgeon chiefs performed 20 cases in 1989 to 1990 and 20 cases in 2018 to 2019 versus the 10th percentile performed 3 cases in 1989 to 1990 and 5 cases in 2018 to 2019, respectively. Both a significant increase in ESC volume as well as more disparate variability in ESC volume were found among surgeon juniors. From 1989 to 1990, surgeon juniors in the 10th percentile completed 1 case, compared with 15 cases in the 90th percentile. From 2018 to 2019, surgeon juniors within the 10th percentile performed 8 cases, compared with 37 cases in the 90th percentile. Over time, ESC volume variability increased from 14 cases between the 10th and 90th percentile to 29 cases between individual surgeon junior residents (P < .001).
      Figure thumbnail gr6
      Fig 6Heterogeneity of Endocrine Surgery case volume from academic year 1989 to 1990 to 2018 to 2019 stratified by resident experience level. (A) Surgeon Chief. (B) Surgeon junior.

      Discussion

      Projected estimates of endocrine surgical disease and workforce considerations suggest that general surgeons, AAES-trained and non-AAES trained alike, will continue to be called on to perform a significant portion of ESCs within their clinical practice. Adequate training of surgeons in the field of endocrine surgery is paramount to meet this increasing demand. Highly variable experience among graduating residents has raised concerns of adequate operative exposure to the broad array of endocrine disorders.
      • Zarebczan B.
      • McDonald R.
      • Rajamanickam V.
      • Leverson G.
      • Chen H.
      • Sippel R.S.
      Training our future endocrine surgeons: a look at the endocrine surgery operative experience of US surgical residents.
      Contributing factors proposed include narrowed operative experience during senior training, increased training demands from technical innovations, increased subspecialization after GS training, and encroachment by nongeneral surgery specialty programs or fellowships and AAES fellows.
      • Zarebczan B.
      • McDonald R.
      • Rajamanickam V.
      • Leverson G.
      • Chen H.
      • Sippel R.S.
      Training our future endocrine surgeons: a look at the endocrine surgery operative experience of US surgical residents.
      • Cortez A.R.
      • Katsaros G.D.
      • Dhar V.K.
      • et al.
      Narrowing of the surgical resident operative experience: a 27-year analysis of national ACGME case logs.
      • Drake F.T.
      • Aarabi S.
      • Garland B.T.
      • et al.
      Accreditation Council for Graduate Medical Education (ACGME) surgery resident operative logs: the last quarter century.
      We completed a longitudinal review of nationwide data spanning a 30-year period of GS resident ESC volume. We determined that despite recent increases in the minimum requirements, the mean number of ESCs remains well above the current ACGME standards. Additional compelling findings from our study provide greater understanding of the current state of GS training in endocrine surgery in the United States. After years of steady increases, the number of ESCs performed by GS residents is currently in decline. The decline is primarily attributable to a decrease in thyroid procedures, which affects both chief residents and more junior trainees. The majority of the ESCs performed by GS residents have shifted from the chief resident year to other years of residency. Lastly, training is becoming more heterogeneous and disparate over time, and this is more pronounced within junior trainees.
      Our study is the first to demonstrate a modest decline in GS operative endocrine experience during the past decade. The expansion of AAES-accredited fellowships in endocrine surgery coincides with this decline, as does a significant growth in the number of graduating residents despite a concurrent decrease in GS programs. The impact of co-existing fellowships on the GS operative experience is variable.
      • Hanks J.B.
      • Ashley S.W.
      • Mahvi D.M.
      • et al.
      Feast or famine? The variable impact of coexisting fellowships on general surgery resident operative volumes.
      Pediatric and vascular surgery fellowships in particular correlate with significant nationwide longitudinal decreases in resident operative experience within those subspecialty fields.
      • Potts J.R.
      Effect of new fellowship programs on resident case volume in pediatric surgery.
      ,
      • Shannon A.H.
      • Robinson W.P.
      • Hanks J.B.
      • Potts J.R.
      Impact of new vascular fellowship programs on vascular surgery operative volume of residents in associated general surgery programs.
      In the case of endocrine surgery, one co-located endocrine fellowship led to an increase in resident ESC volume lasting at least 5 years.
      • Hanks J.B.
      • Ashley S.W.
      • Mahvi D.M.
      • et al.
      Feast or famine? The variable impact of coexisting fellowships on general surgery resident operative volumes.
      ,
      • Wiseman J.E.
      • Ituarte P.H.G.
      • Ro K.
      • et al.
      The effect of a dedicated endocrine surgery program on general surgery training: a single institutional experience.
      Recently Fashandi et al performed a comprehensive evaluation of ESC volume by graduating GS residents at programs offering AAES fellowships. They found that by year 10 of AAES fellowship programs, there was neither an increase nor decrease in ESCs performed by residents in co-located GS programs.

      Fashandi AZ, Hanks JB, Ramirez AG, Potts JR, Smith PW New endocrine fellowship programs do not decrease the endocrine surgery experience of residents in co-located general surgery programs. Surgery. https://doi.org/10.1016/j.surg.2020.05.043. Accessed June 10, 2020.

      This would suggest that the presence of AAES fellowships is not a cause of the recent decline in ESC volume noted in our findings.
      There is significant evidence of increased competition for ESCs between surgical subspecialties in the past 2 decades. The expanding role of otolaryngologists in the training and subsequent practice of endocrine surgery is reflected in the number of parathyroid and thyroid publications authored representing an increasing contribution to the body of literature over the past 2 decades.
      • Terris D.J.
      • Chen N.
      • Seybt M.W.
      • Gourin C.G.
      • Chin E.
      Emerging trends in the performance of parathyroid surgery.
      ,
      • Terris D.J.
      • Seybt M.W.
      • Siupsinskiene N.
      • Gourin C.G.
      • Chin E.
      Thyroid surgery: changing patterns of practice.
      Otolaryngology membership in the American Thyroid Association, a multi-disciplinary professional society for the thyroid diseases, has increased currently representing (144/354) 40.7% of surgical faculty and fellows. Additionally, there are currently 4 endocrine surgery fellowships accredited by the American Head and Neck Society open to both ENT and GS graduates compared with 23 fellowships recognized by the AAES. Regarding ESC exposure during training, Zarebczan et al
      • Zarebczan B.
      • McDonald R.
      • Rajamanickam V.
      • Leverson G.
      • Chen H.
      • Sippel R.S.
      Training our future endocrine surgeons: a look at the endocrine surgery operative experience of US surgical residents.
      examined the case volume of thyroid and parathyroid operations between 2004 and 2008 among US general surgery and otolaryngology (ENT) residents. Although they found a 15% increase in GS cases, ENT residents performed more than twice as many thyroid and parathyroid operations as GS residents. Consistent with our findings, thyroidectomies accounted for the majority of the increase.
      • Zarebczan B.
      • McDonald R.
      • Rajamanickam V.
      • Leverson G.
      • Chen H.
      • Sippel R.S.
      Training our future endocrine surgeons: a look at the endocrine surgery operative experience of US surgical residents.
      The parathyroidectomy volume of GS residents also increased but to a lesser extent as the volume of parathyroid cases performed by ENT residents.
      • Zarebczan B.
      • McDonald R.
      • Rajamanickam V.
      • Leverson G.
      • Chen H.
      • Sippel R.S.
      Training our future endocrine surgeons: a look at the endocrine surgery operative experience of US surgical residents.
      Kay et al
      • Kay S.
      • Miller R.
      • Kraus D.
      • Terris D.J.
      Evolving phenotype of the head and neck surgeon.
      reviewed the ENT residency case log data, which found a 288% increase in endocrine cases from 18.4 in 1996 to 71.5 in 2015. The increased ESCs in ENT training corresponds with the rise in clinical practice postresidency training without subspecialty certification.
      A higher number of GS residents per program may have led to increased competition among residents within the same program despite the increased demand for endocrine surgery. What constitutes adequate training and how it is defined is a topic of considerable debate across surgical education. The recent increase in minimum standards of ESCs represents less than 2% of the major cases required for graduation.
      ACGME Review Committee for Surgery
      Defined category minimum numbers for general surgery residents and credit role.
      Consistent with our findings, a 2001 study found graduating GS residents performed less than 30 endocrine procedures during residency, approximately 11% of the average experience of AAES fellows who anticipate performing greater than 250 cases annually. The study also highlighted the relative lack of high-volume endocrine surgeons serving as mentors.
      • Sosa J.A.
      • Wang T.S.
      • Yeo H.L.
      • et al.
      The maturation of a specialty: workforce projections for endocrine surgery.
      ,
      • Solorzano C.C.
      • Sosa J.A.
      • Lechner S.C.
      • Lew J.I.
      • Roman S.A.
      Endocrine surgery: where are we today? A national survey of young endocrine surgeons.
      Better outcomes have been extensively associated with surgeon volume. Endocrine volume has been defined as low (<50 cases/year), intermediate (55−99 cases/year) and high (>100 cases/year) for parathyroid and thyroid operations combined.
      • Stavrakis A.I.
      • Ituarte P.H.G.
      • Ko C.Y.
      • Yeh M.W.
      Surgeon volume as a predictor of outcomes in inpatient and outpatient endocrine surgery.
      More recently, improved total thyroidectomy outcomes with acceptably low complication rates were demonstrated for surgeons performing >25 cases per year.
      • Adam M.A.
      • Thomas S.
      • Youngwirth L.
      • et al.
      Is there a minimum number of thyroidectomies a surgeon should perform to optimize patient outcomes?.
      For adrenal surgery, low volume has been defined as <1 case per year, intermediate volume as 2 to 3 cases/year, and high volume as >4 cases per year.
      • Park H.S.
      • Roman S.A.
      • Sosa J.A.
      Outcomes from 3144 adrenalectomies in the United States: which matters more, surgeon volume or specialty?.
      Newer evidence suggests that this may be a lower estimate than necessary to decrease complications after adrenalectomy recommending a dichotomous categorization of < or ≥6 cases new year to define low versus high volume, respectively.
      • Anderson K.L.
      • Thomas S.M.
      • Adam M.A.
      • et al.
      Each procedure matters: threshold for surgeon volume to minimize complications and decrease cost associated with adrenalectomy.
      Regardless of the definition used, our study found that few GS resident graduates meet the requirements of a high-volume endocrine provider in the past year of training. It is thus, the authors’ opinion that the endocrine surgery experience of most GS graduates is not sufficient to create safe and competent comprehensive endocrine surgeons.
      Individuals also seek fellowship training to limit their practices to a particular sphere and find this is easier with additional subspecialty training that provides greater exposure and competency building in a particular surgical area. Between 2005 and 2013, there has been a significant increase in the percentage of endocrine operations performed by AAES surgeons.
      • Kuo J.H.
      • Pasieka J.L.
      • Parrack K.M.
      • Chabot J.A.
      • Lee J.A.
      Endocrine surgery in present-day academia.
      In 2006, fellowship graduates performed an average of 162 endocrine procedures per year with a range of 37 to 370.
      • Sosa J.A.
      • Wang T.S.
      • Yeo H.L.
      • et al.
      The maturation of a specialty: workforce projections for endocrine surgery.
      When comparing AAES surgeons and non-AAES surgeons in practice, the majority of AAES surgeons qualify as high-volume endocrine surgeons, 57% for parathyroid and thyroid surgeries and 70% for adrenal surgeries versus 6% and 18%, respectively.
      • Kuo J.H.
      • Pasieka J.L.
      • Parrack K.M.
      • Chabot J.A.
      • Lee J.A.
      Endocrine surgery in present-day academia.
      Endocrine surgeons were also more likely to perform laparoscopic adrenal procedures than general surgeons and urologists and had the shortest hospital stay.
      • Lindeman B.
      • Hashimoto D.A.
      • Bababekov Y.J.
      • et al.
      Fifteen years of adrenalectomies: impact of specialty training and operative volume.
      Shin et al
      • Shin J.J.
      • Milas M.
      • Mitchell J.
      • Berber E.
      • Gutnick J.
      • Siperstein A.
      The endocrine surgery job market: a survey of fellows, department chairs, and surgery recruiters.
      found ~90% of AAES graduates have a practice that is greater than 50% endocrine procedures and 45% have an entirely endocrine procedural practice. Of those working at academic centers, Kuo et al
      • Kuo J.H.
      • Pasieka J.L.
      • Parrack K.M.
      • Chabot J.A.
      • Lee J.A.
      Endocrine surgery in present-day academia.
      found that endocrine procedures comprise approximately 65% of an AAES-trained surgeon’s practice. Particularly telling of the benefits of fellowship training is a survey that found 90% of graduating fellows felt comfortable performing parathyroidectomies and 97% felt comfortable performing thyroidectomies.
      • Solorzano C.C.
      • Sosa J.A.
      • Lechner S.C.
      • Lew J.I.
      • Roman S.A.
      Endocrine surgery: where are we today? A national survey of young endocrine surgeons.
      Among general surgery residents, most ESCs are completed prior to the chief year. We noted an increasing divergence in this trend created primarily by more junior trainees performing a larger proportion of ESCs. Similar to our findings, Drake et al
      • Drake F.T.
      • Horvath K.D.
      • Goldin A.B.
      • Gow K.W.
      The general surgery chief resident operative experience: 23 years of national ACGME case logs.
      noted that the ESC volume has remained unchanged for chief GS residents and demonstrated a narrowing case mix in their operative cases as a partial explanation. Other potential reasons behind this observation involve the increased sharing of cases with more junior trainees once chief residents have satisfied the ACGME volume criteria, relatively fewer years in practice of AAES endocrine surgeons resulting in assignment of more junior residents to assist with cases, and rotation structuring. At many institutions, endocrine surgery is a joint service line with breast surgery and soft tissue cancers, surgical oncology, hepatobiliary surgery, or minimally invasive and metabolic surgery. Within joint service rotations, the availability of residents lends itself to more junior level resident performing ESCs on any given day. The option of a flexible dedicated rotation for chief residents interested in incorporating endocrine surgery as part of their routine clinical practice is one possible way to increase the endocrine surgical experience during training.
      AAES members have mixed opinions regarding the ESC volume among GS residents. Based on an expert consensus survey, most AAES members agreed that postgraduate year 3 and 4 residents can perform a total thyroidectomy for benign disease and targeted parathyroidectomy. They affirmed that GS residents are competent in performing common endocrine procedures independently by graduation assuming no anatomic variations, expected longer operative time, acceptably higher complication rates, and need for larger incisions.
      • Phitayakorn R.
      • Kelz R.R.
      • Petrusa E.
      • et al.
      Expert consensus of general surgery residents' proficiency with common endocrine operations.
      Their results harbor considerable selection bias as most responders were high-volume AAES members with a greater than 50% endocrine clinical practice at academic centers. These responders supply higher exposure and quality of learning opportunities for their residents who are also more likely to exceed minimal volume requirements.
      • Anderson K.L.
      • Thomas S.M.
      • Adam M.A.
      • et al.
      Each procedure matters: threshold for surgeon volume to minimize complications and decrease cost associated with adrenalectomy.
      Regardless, these consensus opinions likely contribute to the trend of performing ESCs earlier in training. With greater than 80% of fellowship-bound residents nationwide, the phenomenon of early tracking, or informal concentration in their future specialization area during GS training, may partially explain the increased heterogeneity in ESC volume over time.
      • Coleman J.J.
      • Esposito T.J.
      • Rozycki G.S.
      • Feliciano D.V.
      Early subspecialization and perceived competence in surgical training: are residents ready?.
      Endocrine fellowship bound residents perform significantly more endocrine cases than their GS colleagues.
      • Hanks J.B.
      • Ashley S.W.
      • Mahvi D.M.
      • et al.
      Feast or famine? The variable impact of coexisting fellowships on general surgery resident operative volumes.
      It is also possible that the increased number of GS residents within fewer graduating residency programs has led to increased competition over ESCs contributing more to the heterogeneity seen among residents.
      There are several notable limitations to our study. The ACGME operative case log system is arguably the most comprehensive database for examining resident case volume. However, it is retrospective observational data and subject to inherent biases including the inability to control for unmeasured variables and reliance of self-reporting making it vulnerable to reporting errors.
      • Balla F.
      • Garwe T.
      • Motghare P.
      • et al.
      Evaluating coding accuracy in General Surgery Residents' Accreditation Council for Graduate Medical Education procedural case logs.
      Underreporting, in particular, is a concern as some residents may not log cases completely once they have met the minimum case volume for each required category. ACGME operative case log data does not capture information on the more subjective educational value of the cases reported.
      • Nygaard R.M.
      • Daly S.R.
      • Van Camp J.M.
      General surgery resident case logs: do they accurately reflect resident experience?.
      • Shah D.
      • Haisch C.E.
      • Noland S.L.
      Case reporting, competence, and confidence: a discrepancy in the numbers.
      We were unable to assess the impact of all potential contributors leading to the decline in ESCs and increased heterogeneity in training. In addition to those mentioned previously, these may include program size, academic versus community training programs, regional variability of endocrine fellowship programs and of practicing AAES endocrine surgeons,
      • Krishnamurthy V.D.
      • Jin J.
      • Siperstein A.
      • Shin J.J.
      Mapping endocrine surgery: workforce analysis from the last six decades.
      and degree of encroachment by non-GS specialty programs and fellowships and non-ACGME-accredited GS programs.
      In conclusion, with the growing number of endocrine cases being performed, there is a need to train surgeons competent in endocrine surgery highlighting the importance of exposure to endocrine procedures and mentoring. The number of endocrine procedures performed by GS residents has declined in recent years most notably in thyroidectomies, while still exceeding the minimum number of ACGME required cases. Future investigation should focus on determining modifiable factors accounting for the recent decline in endocrine surgical experience and is a trend that warrants close watching.

      Funding/Support

      This research was funded in part by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number T32HL007849. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

      Conflict of interest/Disclosures

      Dr Potts is a full-time employee of the ACGME. He has no voice or vote in accreditation decisions made by the RRC-Surgery. The other authors involved in this manuscript have no personal conflicts of interest to disclose.

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