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Comment & Response
September 15, 2021

Competence Is About Skill, Not Procedure Case Numbers—Reply

Author Affiliations
  • 1Department of Surgery, Harbor-University of California, Los Angeles Medical Center, Torrance
  • 2Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
JAMA Surg. 2022;157(1):81-82. doi:10.1001/jamasurg.2021.4415

In Reply We thank Gallagher and colleagues for their insightful comments and for the opportunity to clarify our work.1 The purpose of our multiinstitutional study was to evaluate the decline in general surgery resident physicians’ operative volume during the first 4 months of the COVID-19 pandemic and assess if all postgraduate years were affected equally. In reviewing 1358 general surgery resident case logs, we found that operative volume declined by 33.5% from March to June 2020 compared with March to June 2018 and 2019 and equally affected residents at all levels of training. Gallagher et al point out that increased procedure volume may not be reliably associated with increased surgeon skill and advocate that resident procedural knowledge and basic technical skills should be acquired outside of the operating room prior to fine tuning operative skills on actual patients. While we agree that a strong foundation of procedural knowledge and technical skills are fundamental and necessary aspects of surgical training, we also believe that operative experience during residency is vital in preparing residents for independent practice or fellowship. Prior studies have shown that general surgery resident physician operative volumes are positively associated with competence and progressive autonomy.2,3 However, there is significant variability in the number of procedures each resident physician must perform to achieve competence.2,3 We fundamentally agree with Gallagher and colleagues that there is little value in setting absolute minimum case volume requirements in the absence of direct evaluations of operative competence. We feel that the COVID-19 pandemic has accelerated the need to develop a competency-based evaluation system to use in conjunction with, or in lieu of, minimum case volume requirements. This would allow for better determination of which residents are prepared to graduate under the American Board of Surgery’s modified training requirements during the pandemic.

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