key: cord-0744339-779pfr2i
authors: Ammann, Allison M.; Cortez, Alexander R.; Vaysburg, Dennis M.; Winer, Leah K.; Sussman, Jeffrey J.; Potts, John R.; Van Haren, Robert; Quillin, Ralph Cutler
title: Examining the Impact of COVID-19 Restrictions on the Operative Volumes of US General Surgery Residents
date: 2021-06-12
journal: Surgery
DOI: 10.1016/j.surg.2021.06.003
sha: 78c3a3a1a559a96c5dfbdff199582afdf01cfece
doc_id: 744339
cord_uid: 779pfr2i

BACKGROUND: In March 2020, the COVID-19 virus global pandemic forced healthcare systems to institute regulations including the cancellation of elective surgical cases, which likely decreased resident operative experience. The objective of this study was to determine if the COVID-19 pandemic affected operative experiences of U.S. general surgery residents. METHODS: The operative experience of general surgery residents was examined nationally and locally. Aggregate Accreditation Council for Graduate Medical Education (ACGME) case logs for 2018-2019 (pre-COVID) and 2019-2020 (COVID) graduates were compared using national mean cumulative operative volume for total major and surgeon chief cases. Locally, ACGME case logs were used to analyze the operative experience among residents at a single, academic center. Average operative volumes per month per resident during peak COVID-19 quarantine months were compared with those the previous year. RESULTS: Compared with 2019 graduates, 2020 graduates completed 1.5% fewer total major cases (1055 ± 155 vs 1071 ± 150, p=0.011). This was most evident during chief year, with 8.4% fewer surgeon chief cases logged in 2020 compared to 2019 (264 ± 67 vs 289 ± 69, p < 0.001). Institutional data revealed that during the peak of the pandemic, residents across all levels completed 42.5% fewer total major operations (12 ± 11 vs 20 ± 14, p < 0.001). This effect was more pronounced among junior residents compared with senior and chief residents. CONCLUSIONS: The COVID-19 pandemic was associated with decreased resident case volume. The ramifications of the COVID-19 pandemic for operative competency and autonomy should be carefully examined.

In early March of 2020, the World Health Organization declared the novel coronavirus disease 2 (COVID-19) a pandemic [1] . By that time, several cases of COVID-19 had been diagnosed in the United 3 States, and many large US cities became epicenters with a rapid increase in the volume of critically ill 4 patients. Major initiatives were undertaken to limit the spread of this virus within the healthcare system. 

To evaluate the impact of COVID-19 quarantine policies on surgical resident operative 20 experience on the national and local levels, two complementary methods were employed. Surgical 21 residents at ACGME-accredited residencies maintain individual case logs to monitor operative experience 22 during training. These case logs are accessible to the individual programs in real time for monitoring 23 resident progress. Upon graduation, each resident's cumulative case log is submitted to the ACGME for 1 residents may log cases as surgeon chief or TA such that for non-chiefs, total major cases parallels 2 surgeon junior whereas for chiefs, surgeon chief and total major cases may differ depending on TA cases 3 [6] . No individual or program level data is provided within these national aggregate reports.

To study the impact on the national level, aggregate ACGME case logs were used. National mean 5 operative volume was examined for total major and surgeon chief cases. Cumulative operative 6 experience, which represents a graduating resident's entire clinical operative experience over their five or 7 more years of training, was then compared between 2018-2019 (pre-COVID) and 2019-2020 (COVID) 8 graduates by using total major cases. Surgeon chief cases, which can only be logged during a resident's 9 chief year and therefore represents chief operative experience, were also examined between the same 10 groups.

Next, to evaluate the impact of COVID-19 on a more granular level, the operative experience 12 among residents at a single, academic tertiary care center (University of Cincinnati, Cincinnati, Ohio) was 13 examined. ACGME operative case logs for general surgery residents from 2018 to 2020 were queried. 14 Analysis was performed among all residents, as well as by residency level, for which residents were 15 grouped into junior (R1-R2), senior (R3-R4), and chief (R5) cohorts. Case log data was aggregated from 16 31 residents in 2019 compared with 30 residents in 2020, which represented 100% of active residents for 17 both years. Baseline demographics of these two groups are listed in (6 ± 7 vs 12 ± 10, p=0.004) and senior residents had a 43.5% decrease (15 ± 11 vs 26 ±16, p < 0.001) in 1 average total major cases per month. There was not a significant decrease in monthly total major cases for 2 chief residents (16 ± 11 vs 21 ±13, p=0.177) (FIGURE 2). However, there was a notable decrease in 3 logged surgeon chief cases among chief residents in 2020 compared with 2019 (12 ± 7 vs 19 ± 11, 4 p=0.041). For the entire 2020 cohort, decreased operative volume was observed in eight operative 5 domains, including skin and soft tissue, stomach, hernia, biliary, endocrine, plastic and both basic and intraoperative decision-making, which is immensely valuable for near-graduating residents approaching 5 fellowship or independent practice. Locally, although the number of monthly surgeon chief cases 6 decreased, total major cases did not decline as a result of a slight increase in TA cases. This suggests that 7 to optimize their more limited opportunities during COVID-19, residents more frequently double-8 scrubbed with faculty, allowing chiefs to lead junior residents through cases. Ultimately, our local data 9 demonstrate that all residents were impacted on some level. However, the effects by level will be 10 important to consider in progression through general surgery residency, with junior residents requiring 11 more attention to technical skills and chief residents requiring experiences focusing on operative 12 autonomy.

Although there is controversy regarding the correlation between ACGME case logs and operative 14 competency or technical proficiency, the global reduction in operative experience during COVID-19 is 15 concerning as studies have shown an association between higher operative volume and improved 16 outcomes, which has been used as a surrogate for competence [16] [17] [18] [19] [20] . In examining how to remedy the 17 volume deficit observed in this study, it is evident that surgical education across the U.S. will need to 18 adapt and modernize to continue high-quality education of residents. Video-based education (VBE), 19 which has been previously shown to be an effective technique for operating room preparation, could 20 provide an easily accessible and cost-effective resource for residents to supplement their operative 

WHO Declares COVID-19 a Pandemic

COVID-19 Pandemic and 7 the Lived Experience of Surgical Residents, Fellows, and Early-Career

American College of Surgeons

Effect of COVID-19 on Surgical Training Educ

Case Reporting, Competence, and Confidence: A 13 Discrepancy in the Numbers

The ACGME Case Log System May