Mean operative cases done per resident by postgraduate year from March 1 through June 30 in 2018, 2019, and 2020.
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Purdy AC, de Virgilio C, Kaji AH, et al. Factors Associated With General Surgery Residents’ Operative Experience During the COVID-19 Pandemic. JAMA Surg. 2021;156(8):767–774. doi:10.1001/jamasurg.2021.1978
How did general surgery resident operative volume change during the first 4 months of the US COVID-19 pandemic, and were all postgraduate year levels equally affected?
In this review of 1358 resident case logs, general surgery resident operative volume declined by 33.5% in March to June 2020 compared with March to June 2018 and 2019 and affected residents in every level of training.
These findings illustrate the significant negative effect of the COVID-19 pandemic on general surgery resident operative experience, highlighting the importance of identifying future mitigation strategies.
The suspension of elective operations in March 2020 to prepare for the COVID-19 surge posed significant challenges to resident education. To mitigate the potential negative effects of COVID-19 on surgical education, it is important to quantify how the pandemic influenced resident operative volume.
To examine the association of the pandemic with general surgical residents’ operative experience by postgraduate year (PGY) and case type and to evaluate if certain institutional characteristics were associated with a greater decline in surgical volume.
Design, Setting, and Participants
This retrospective review included residents’ operative logs from 3 consecutive academic years (2017-2018, 2018-2019, and 2019-2020) from 16 general surgery programs. Data collected included total major cases, case type, and PGY. Faculty completed a survey about program demographics and COVID-19 response. Data on race were not collected. Operative volumes from March to June 2020 were compared with the same period during 2018 and 2019. Data were analyzed using Kruskal-Wallis test adjusted for within-program correlations.
Main Outcome and Measures
Total major cases performed by each resident during the first 4 months of the pandemic.
A total of 1368 case logs were analyzed. There was a 33.5% reduction in total major cases performed in March to June 2020 compared with 2018 and 2019 (45.0 [95% CI, 36.1-53.9] vs 67.7 [95% CI, 62.0-72.2]; P < .001), which significantly affected every PGY. All case types were significantly reduced in 2020 except liver, pancreas, small intestine, and trauma cases. There was a 10.2% reduction in operative volume during the 2019-2020 academic year compared with the 2 previous years (192.3 [95% CI, 178.5-206.1] vs 213.8 [95% CI, 203.6-223.9]; P < .001). Level 1 trauma centers (49.5 vs 68.5; 27.7%) had a significantly lower reduction in case volume than non–level 1 trauma centers (33.9 vs 63.0; 46%) (P = .03).
Conclusions and Relevance
In this study of operative logs of general surgery residents in 16 US programs from 2017 to 2020, the first 4 months of the COVID-19 pandemic was associated with a significant reduction in operative experience, which affected every PGY and most case types. Level 1 trauma centers were less affected than non–level 1 centers. If this trend continues, the effect on surgical training may be even more detrimental.
Ever since the first reported case in the US on January 20, 2020, COVID-19 has changed personal and professional lives. On March 11, 2020, the World Health Organization declared COVID-19 a pandemic, and the following day, the US declared the pandemic a national emergency.1,2 On March 13, 2020, the American College of Surgeons issued a statement urging surgeons to limit elective procedures to avoid overwhelming our health care infrastructure.3
The pandemic has posed unique challenges for surgical residencies. Programs faced the arduous task of restructuring their residencies to protect trainees’ well-being and maintain enough healthy personnel to provide patient care while also preserving residents’ educational experiences. Strategies included separating residents into groups that alternate 1 week of in-person duty with 1 week of telehealth work from home and separating residents into operating, inpatient, and outpatient groups.4-8 Resident education has undoubtedly been affected with the net effect of residents spending less time in the operating room. While programs have created innovative online didactic curriculums, this does not replace the necessary hands-on experience in the operating room.5,6,9-11
Even prior to COVID-19, questions about adequate preparation for independent practice of recent residency graduates have been raised as overall resident autonomy has decreased over time.12,13 A significant decline in residents’ operative experience during the pandemic could further exacerbate this problem. It is important to quantify the decline in residents’ operative volume during the pandemic to develop a plan moving forward. Prior studies have reported decreased surgical volumes during the pandemic; however, they are single-institution studies or surveys, where residents and faculty reported perceived decreases in operative volume.5,7,14-16 There has not yet been a multi-institutional study evaluating resident case logs during the first 4 months of the COVID-19 pandemic, to our knowledge.
The primary goals of our multi-institutional study were to quantify the magnitude of the decline in general surgery residents’ operative volume during the first 4 months of the COVID-19 pandemic (March-June 2020) and to determine if the decline was associated with outcomes in all postgraduate years (PGY) and operative case types. Second, we evaluated if certain institutional characteristics were associated with a greater decline in surgical volume, whether any COVID-19–associated decline was significant enough to be associated with the case volume for the entire academic year, and what supplemental educational strategies were incorporated during the pandemic.
This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Sixteen general surgery programs from an established US Surgery Educators Workgroup participated in the study. This workgroup includes educators from university-based, university-affiliated, and independent programs of various sizes. These institutions include Brookwood Baptist Health; Cedars-Sinai; Columbia University Medical Center; Harbor-University of California, Los Angeles; Houston Methodist Hospital; Loma Linda University; Santa Barbara Cottage; Southern Illinois University; Stanford University; University of California, Davis; University of California, Irvine; University of California, Los Angeles; University of California, San Francisco-Fresno; University of Nebraska; University of Southern California; and University of Washington. The study was considered exempt from requiring institutional review board approval by Cedars-Sinai Medical Center because no identifying information was used.
Accreditation Council for Graduate Medical Education (ACGME) operative logs were collected from July 1, 2017, through June 30, 2020, representing 3 consecutive academic years (2017-2018, 2018-2019, and 2019-2020) for categorical general surgery residents at participating programs by PGY. Data included total major cases and case type. Data on race were not collected. Total major cases are defined by the ACGME as procedures performed primarily by the resident under faculty supervision. To determine case type, major cases were divided into ACGME-defined categories, including abdominal (subcategories: biliary, hernia, liver, and pancreas), alimentary (subcategories: esophagus, stomach, small intestine, large intestine, appendix, and anorectal), breast (subcategories: mastectomy and axilla), endocrine (subcategory: thyroid and parathyroid), endoscopy, head and neck, basic laparoscopy, complex laparoscopy, operative trauma, pediatric, plastics, skin and soft tissue, thoracic, and vascular (subcategory: access).
Program directors were asked to complete a survey about the institution’s characteristics and response to the pandemic. Program information collected included program type (university based, university affiliated, or independent), trauma center status (level 1 or non–level 1), number of days that elective surgeries were canceled at the institution from March to June 2020, and how restrictive the institution was in scheduling operations during the height of the pandemic. Most restrictive was defined as only allowing emergency surgery with no elective cases. Moderately restrictive was defined as only allowing emergencies and cancer operations. Least restrictive was defined as allowing emergencies, cancer operations, and some elective cases for patients with significant symptoms. Program directors were asked if programs incorporated supplemental education during the pandemic, including virtual didactics and conferences, resident participation in telemedicine clinics, and increased resident access to simulation trainers.
The main outcome measure was the mean number of total major cases performed by each resident during the first 4 months of the COVID-19 pandemic (March 1 to June 30, 2020). This mean was compared with the mean number of total major cases performed by each resident during the same 4-month period in the 2 prior academic years (2018 and 2019). Mean total cases performed was also determined based on PGY and by case type. Secondary outcome measures included the mean number of total major cases performed by each resident during the entire 2019-2020 academic year. This mean was compared with the 2 prior academic years (2017-2018 and 2018-2019). A stratified analysis was used to determine if different program characteristics were associated with a greater decline in operative volume.
Data were collected into a Microsoft Excel database (Microsoft Corp) and imported to SAS format version 9.4 (SAS Institute) for statistical analyses. All variables were evaluated with descriptive statistics. Because operative volumes were not normally distributed, they are reported as medians with interquartile ranges; case volumes between years were compared using the Kruskal-Wallis test adjusted for within-program correlations of outcomes. The percent reduction of case volume from 2018 and 2019 (pre–COVID-19) to 2020 (during COVID-19) is also described. P < .05 was considered statistically significant.
We reviewed the operative case logs of 1358 categorical general surgery residents from 2017 to 2020. In terms of program type, 771 resident case logs (56.8%) were from 8 university-based programs, 407 (30.0%) from 5 university-affiliated programs, and 180 (13.2%) from 3 independent programs. Twelve programs were based at level 1 trauma centers (representing 1006 resident case logs [74.1%]), whereas 4 programs were not (352 case logs [25.9%]). All programs had some operations canceled during COVID-19, with varying degrees of restrictions on scheduling cases. The degrees of restrictions were as follows: 275 resident case logs (20.2%) were from 4 programs with the least restrictions, 859 (63.2%) from 10 programs with moderate restrictions, and 224 (16.5%) from 2 programs with the most restrictions. Programs restricted surgical scheduling for a median (interquartile range) of 49 (42-83) days from March to June 2020. Demographics are summarized in Table 1. Residency educational changes included online lectures (16 programs [100%]), online grand rounds (15 programs [94%]), online morbidity and mortality (13 programs [81%]), resident participation in telemedicine clinics (9 programs [56%]), virtual mock orals (8 programs [50%]), and increased resident access to simulation trainers (3 programs [19%]).
In March to June 2018 and 2019, each categorical resident performed a mean of 67.8 (95% CI, 62.8-72.2) and 67.5 (95% CI, 60.9-74.2) major cases, respectively, compared with 45.0 major cases (95% CI, 36.1-53.9) in March to June 2020 (P < .001), representing a 33.5% reduction in operative volume during the pandemic. Every PGY level had a significant reduction in total major case volume (Table 2 and Figure). Compared with before COVID-19 (March-June 2018 and 2019), PGY1 residents in the COVID-19 period (March-June 2020) performed 30.8% fewer cases (mean [95% CI], 32.5 [25.8-39.2] vs 22.5 [15.8-29.2]; P = .002); PGY2 residents performed 34.7% fewer cases (mean [95% CI], 57.3 [48.5-66.1] vs 37.4 [29.1-45.8]; P < .001); PGY3 residents performed 34.1% fewer cases (mean [95% CI], 85.4 [78.0-92.7] vs 56.3 [42.7-69.0]; P < .001); PGY4 residents performed 34.9% fewer cases (mean [95% CI], 86.9 [78.1-95.6] vs 56.6 [47.1-66.3]; P < .001); and PGY5 residents performed 30.1% fewer cases (mean [95% CI], 77.4 [65.6-89.2] vs 54.1 [44.9-67.8]; P < .001). There were statistically significant reductions in March to June 2020 compared with March to June 2018 and 2019 for all case types except liver, pancreas, small intestine, and operative trauma cases (Table 3).
For the entire academic year, each resident performed a mean (95% CI) of 215.0 (206.4-223.5) cases in 2017-2018, 212.5 (200.8-224.2) cases in 2018-2019, and 192.3 (178.5-206.1) cases in 2019-2020, representing a 10.2% reduction in surgical case volume during the 2019-2020 academic year (P < .001). When adjusted for within-program correlations, all PGY levels saw a significant decline in operative volume in the 2019-2020 academic year except PGY1 residents (Table 2).
There was a significant reduction in mean cases performed in March to June 2020 compared with March to June 2018 and 2019 at both level 1 trauma centers (mean [95% CI], 49.5 [42.6-56.3] vs 68.5 [62.7-74.4]; 27.7% reduction; P < .001) and non–level 1 trauma centers (mean [95% CI], 33.9 [8.1-59.6] vs 63.0 [55.7-70.3]; 46% reduction; P < .001). In multivariable analysis adjusted for trauma center status, year, and within-program correlations, trauma centers have a major case load of 9.1 cases [95% CI 1.0-17.1] greater than nontrauma centers (P = .03). Trauma center status was the only program characteristic that was significantly associated with total major case volume. All program types had a statistically significant decline in mean total major cases during COVID-19; however, this was not associated with program type. The level of restriction in scheduling elective cases also was not significantly associated with the decline in total major cases during the 4-month COVID-19 period. The number of days the institution restricted elective surgeries also was not significantly associated with the reduction in case volume (Table 4).
This retrospective multi-institutional study sought to determine the association of the COVID-19 pandemic with the operative experience of 1358 categorical general surgery residents from 16 US programs. We demonstrated a statistically significant 33.5% decline in operative volume during the first 4 months of the pandemic compared with the same time period in the 2 prior academic years. Residents of every PGY experienced a significant reduction in operative volume, with a similar reduction of total major case volumes, ranging from 30.8% to 34.9%. This 4-month decrease in case volume was enough to be significantly associated with the overall experience for the 2019-2020 academic year, as residents performed 10.2% fewer cases in the 2019-2020 academic year compared with the 2 prior academic years. When stratified by PGY, there was a statistically significant decline in total case volume throughout the entire 2019-2020 academic year for all years except PGY1 residents, likely because first-year residents perform fewer cases at baseline.
To date, there are limited studies on the effect of the pandemic on general surgery resident operative volume and whether all case types are affected. A single-institution study found a 63.3% reduction in operative volume in March and April 2020 compared with March and April 2019.14 However, they used overall operative volume data from the hospital as a proxy for resident operative volume and did not directly look at residents’ ACGME operative logs. In another single-institution report, the authors noted that mean total major cases logged daily by residents decreased from 21 to 10 during the pandemic.7 This report was an early, 6-week experience at a single level 1 trauma center during which the residency schedule was restructured. In our multi-institutional study, we directly analyzed resident operative case logs throughout a 4-month period, included diverse institutions from across the county, divided residents into PGY levels, and described which operative case types were affected.
Given that many hospitals were limited to performing emergent and urgent cases during the COVID-19 pandemic, our study sought to determine which case types were affected. With the exception of trauma, small intestine, liver, and pancreas, all case types in the present study declined in March to June 2020 compared with the same period in 2018 and 2019. The lack of decline in small intestine, liver, and pancreas cases were likely the result of low volume of these case types at baseline. Trauma cases, in contrast, did not decline during the pandemic, likely because they are emergent and not affected by the restriction of elective cases. In fact, a recent study from Philadelphia found that violent trauma, including penetrating trauma and gunshot wounds, significantly increased during Pennsylvania’s stay-at-home order.17 Another study found the majority of operations still being performed during the height of the pandemic were trauma, emergency general surgery, and burn cases.7 This is consistent with our finding that the only program factor that was somewhat protective of a decline in case volume during the pandemic was level 1 trauma center status. However, level 1 trauma center status did not completely prevent the reduction in resident operative experience, as we found that resident case volume at level 1 trauma centers still significantly declined during the pandemic. Not surprisingly, purely elective cases such as endoscopies and hernia surgeries saw the greatest declines, both greater than 50%.
With the cancellation of elective operations and the restructuring of surgical residencies during the pandemic, surgical resident education has undoubtedly been negatively affected. This is highlighted by the fact that the American Board of Surgery (ABS) took immediate action in anticipation of an operative decline. For general surgery residents graduating in 2020, the ABS modified the usual graduation requirements. Traditional graduation requirements include completing 850 total major cases, including 200 during PGY5. For 2020 graduates, the ABS accepted a 10% decrease in total major cases and did not require a minimum of 200 cases during PGY5.18 In our study, chief residents during the 2019-2020 academic year logged a mean of 272 cases during PGY5, which would be sufficient to graduate without the modifications made by the ABS. Although the ABS provided relaxed requirements for 2020 graduates, we also found that PGY1 to 4 residents experienced a significant decrease in operative volume during the first 4 months of COVID-19. One modification the ABS made for residents still in training was allowing 6 months into PGY3 to complete 250 cases, whereas traditionally, 250 cases must be completed by the end of PGY2.18 In our study, this modification was necessary for 2019-2020 PGY2 residents, who only completed a mean of 234.6 cases by the end of PGY2 (mean of 87.3 cases during 2018-2019 PGY1 plus 147.3 cases during 2019-2020 PGY2). As the pandemic continues, it is likely residents in the 2020-2021 academic year will experience ongoing reductions in operative volume.19 It will be important to continue to track surgical residents’ operative volumes as the pandemic rages on. The ABS may need to consider further modifications to graduation requirements for residents graduating after 2020. Hopefully a more drastic alternative, such as extending surgical training, will be unnecessary.
Just as important as ensuring surgical residents meet graduation requirements is ensuring that residents are adequately trained to advance to independent practice or fellowship. Even prior to the pandemic, there have been concerns that many general surgery residency graduates may not be prepared technically for independent practice or fellowship, partly because resident autonomy in the operation room has been decreasing over time.12,13 The decreased operative volume during the pandemic, as reported in our study, may exacerbate this problem. Despite the modified ABS graduation requirements, many residents are worried about their decreased operative experience during the pandemic.14-16 A recent survey reported that less than half of junior residents (34%-42%) and less than two-thirds (58%-65%) of senior residents would feel comfortable graduating with less than the traditional case numbers required by the ABS.15 This suggests that a significant number of residents may have concerns about readiness to graduate without meeting the required minimum technical experience. In the first 4 months of the pandemic, we found that residents performed a mean of 22.7 fewer cases (33.5% decrease) compared with the same period in 2018 and 2019. If cases continue to decline at the same rate for the entire 2020-2021 academic year, the absolute case reduction will grow to 113.5, which is 13.3% of the 850 cases required by the ABS, and residents may have trouble completing enough cases to feel comfortable graduating.
Surgical training programs face unique challenges in identifying strategies to overcome the decrease in operative experience associated with the pandemic. Similar to other studies, we found that several programs transitioned to virtual didactic curriculums.5,6,9,10,15 Nine programs added telehealth visits to augment residents’ clinical training. Three programs increased resident access to surgical simulators. Others have reported using surgical videos to supplement residents’ technical education.9 There may be some positives of this virtual transition because most surgery residents are participating in more didactic education during COVID-19 than previously.15 However, the concern is that none of these measures may fully replace the loss of operative experience because it is difficult to replicate surgery on actual patients using a virtual format. The pandemic may bring into sharper focus the need to create more realistic virtual surgery simulation capabilities to augment surgical training. It will also be important for faculty to commit to prioritizing resident participation and autonomy in the operating room once cases resume.
There are several limitations to our study. First, the pandemic has affected some regions of the US more than others and at different times. Our cohort of programs is neither a random nor an all-inclusive sample of training programs. Our convenience sample of 16 residency programs does represent 7 states with broad geographic distribution: the West (California, Washington), Midwest (Illinois, Nebraska), Northeast (New York), and South (Alabama, Texas). Also, program characteristics in this study only reflect the primary institution and not the other rotation sites. Another limitation is that the major period analyzed was March to June. When data collection began in July 2020, COVID-19 cases were trending down, and many hospitals were well into resuming elective operations. However, we saw additional peaks of COVID-19 cases in late July and November 2020, and further limitations on scheduling elective cases seem inevitable.19 Our study may not tell the whole story of the decline of surgical resident operative volume because the pandemic is not over. Given that prior pandemics have lasted 1 to 2 years, there will likely be an even greater decline in residents’ operative volumes as the pandemic continues.20
During the first 4 months of the COVID-19 pandemic, there was a significant reduction in general surgery residents’ operative volume. This affected all PGY levels and most case types. Level 1 trauma centers were less affected than non–level 1 trauma centers. COVID-19 has undoubtedly affected general surgery resident operative experience, and many surgical residents are concerned that they will not be eligible or prepared technically for graduation because of the pandemic. As the pandemic continues, the long-term implications of COVID-19 on general surgery resident education remains to be seen.
Corresponding Author: Farin Amersi, MD, Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, #8215NT, Los Angeles, CA 90048 (firstname.lastname@example.org).
Accepted for Publication: March 4, 2021.
Published Online: April 30, 2021. doi:10.1001/jamasurg.2021.1978
Author Contributions: Dr Amersi had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Purdy, de Virgilio, Shields Frey, Neville, Donahue, Calhoun, Spain, Amersi.
Acquisition, analysis, or interpretation of data: Purdy, de Virgilio, Kaji, Shields Frey, Lee-Kong, Inaba, Gauvin, Neville, Smith, Salcedo, Calhoun, Poola, Namm, Spain, Dickinson, Tanner, Wolfe, Amersi.
Drafting of the manuscript: Purdy, de Virgilio, Tanner, Amersi.
Critical revision of the manuscript for important intellectual content: Purdy, de Virgilio, Kaji, Shields Frey, Lee-Kong, Inaba, Gauvin, Neville, Donahue, Smith, Salcedo, Calhoun, Poola, Namm, Spain, Dickinson, Wolfe, Amersi.
Statistical analysis: Kaji.
Administrative, technical, or material support: Purdy, Shields Frey, Lee-Kong, Gauvin, Neville, Donahue, Smith, Namm, Spain, Dickinson, Tanner.
Supervision: de Virgilio, Shields Frey, Calhoun, Poola, Amersi.
Conflict of Interest Disclosures: Dr Smith reports personal fees from Stryker Endoscopy outside the submitted work. No other disclosures were reported.
Disclaimer: Dr Kaji is Statistical Editor of JAMA Surgery but was not involved in any of the decisions regarding review of the manuscript or its acceptance.
Meeting Presentation: This study was accepted for presentation at the 92nd Annual Meeting of the Pacific Coast Surgical Association that was planned for February 18-20, 2021, in Monterey, California. However, owing to the COVID-19 pandemic, the meeting was canceled.