17 2
Carlin et al. from Henry Ford Hospital, there was a significant decrease in operative
volume that occurred after July 2003 [ 36 ]. Their analysis found a significant
decrease in operative case volume in the PGY-1, PGY-2, and PGY-4 residents. The
PGY-3 and PGY-5 years appeared unaffected as noted in the article by Ferguson.
This decline in volume was noted for their role as primary surgeon, first assistant, or
teaching assistant roles. These two manuscripts suggested that the work hour’s
restrictions caused a shift of operative cases to the more senior resident years from
the junior resident years. This is worrisome as the burden of operative teaching
would then be spread over fewer years, with less time to work on basic operative
skills prior to needing to master more complicated material.
A larger review of operative case logs submitted to the ACGME as mandated for
graduating chief residents in general surgery demonstrated overall stability in chief
resident case numbers [ 37 ]. The number of total cases performed by resident in the
year prior to duty-hour reforms (2002–2003, mean = 938) was no different than
after (2003–2004, mean = 932). The number of cases performed as a chief resident
was also the same across these years as well (2002–2003, mean = 249 vs. 2003–
2004, mean = 246). This number of cases also was in line with the average number
of chief cases for the prior 5 academic years studied and was well above the estab-
lished minimum of 150 cases set by the American Board of Surgery. Programs who
opted for the variance of an extra 8 hours per week of duty hours (15 programs at
that time) as offered by the ACGME did have more cases performed by their gradu-
ating chief residents, but no change was noted before or after July 2003.
A second large study that looked operative case volume reported there was a
significant change in surgical resident operative volume after the initiation of duty-
hour change in 2003 [ 38 ]. Despite the significant drop in total case numbers, since
the 2003–2004 academic year, there has been an annual increase of 8.8 total major
cases for graduating chief residents. When examining only the chief resident cases,
no significant change was noted after work-hour restrictions went into effect,
despite a prior trend of annual decline of 1.9 cases per year. This study also high-
lighted the change in case types over time for graduating chief residents. For exam-
ple, 47.1% of the total chief resident case volume was alimentary/intra-abdominal
for the earliest cohort (1989–1993), compared to 65.2% in the most recent cohort
(2007–2010). In a similar fashion, there has been a decline in the percentage of
vascular cases performed as chief resident from 21.8% to 11.7% and in trauma
surgery from 8.6% to 3.4%. Some of these changes may reflect changes a shift
away from rotations that do not provided defined category (e.g., cardiac surgery)
for the RRC, the inability of fellows and chief residents to both log a case (thereby
shifting such cases to earlier years in training), and the rise of integrated programs
in areas like vascular surgery. A separate analysis looking specifically at trauma
operations found that there was no significant change in trauma operations after
July 2003 [ 39 ]. There has been a steady decline in the ACGME-designated opera-
tive trauma cases since 1989, when chief residents graduated with a mean of 72.5
trauma cases, compared to a mean of 39.3 since 1999. Clearly, this trend is based
on advances in the management of solid organ injury and the shift to non-opera-
tive/endovascular management [ 40 , 41 ].
D.J. Rea and M. Smith