L. A. Linker1, S. F. Markowiak2, S. A. Toraby2, M. Adair2, S. M. Pannell2, M. M. Nazzal2 1University Of Toledo,College Of Medicine,Toledo, OH, USA 2University Of Toledo,Department Of Surgery,Toledo, OH, USA
Introduction: General surgeons perform 90% of breast cases in the US. In 2003, the ACGME implemented 80-hour work week restrictions. As a result, training programs have moved away from subspecialty exposure, including breast, in favor of more alimentary and laparoscopic cases. To address this, beginning with the 2017-18 academic year, graduating residents will be required to log 40 breast-specific cases, including 5 mastectomies and 5 axillary cases. We analyzed general surgery residents’ exposure to breast surgery in order to find whether training is adequate for transition into practice and meets new ACGME requirements.
Methods: We retrospectively reviewed ACGME logs of graduating general surgery residents for the academic years 1999-00 to 2015-16 in the defined category of “breast.” Individual procedures were analyzed using the total surgeon cases and standard deviation (STD).
Results: For breast reconstruction, cases increased from a mean of 2 per graduating chief in 1999-00 to 5 cases in 2015-16. Mean STD was high at 7.2 cases, indicating heterogeneity in resident experience. Sentinel lymph node biopsy increased to a mean of 8 ± 7 cases per chief from 2001-02 to 2006-07, but has since decreased to 3.9 ± 5 cases in 2015-16. Mean STD over the 15-year period is 6.13 cases, again, illustrating heterogeneity. Excisional and stereotactic breast biopsy cases decreased over a 17-year period, from a mean of 37.6 cases per chief in 1999-00 to 15 cases in 2015-16. Mean STD over this time period is 19.9 cases.
Mastectomy trends varied greatly. Beginning in 2009-10, lumpectomy exposure doubled from a mean of 10.4 cases per chief to 20.2 cases in 2015-16. Radical mastectomies didn’t vary, but modified radical mastectomies decreased. Simple mastectomies increased from a mean of 6 cases in 1999-00 to 10.8 in 15-16. The increase in lumpectomies and simple mastectomies resulted in an increase for total mastectomy cases from 2009-10 to 2015-16.
Conclusion: The combination of duty hour restrictions, breast conserving therapy, earlier diagnosis, and less time devoted to subspecialty areas in residency training has led to fewer complex breast cases for graduates. This led the ACGME to institute a defined breast category and increase the required cases for graduation. Our analysis indicates there is a subset of previous graduates who would not have met this higher standard. We propose the creation of a certificate program for residents who have achieved significant operative and educational exposure in the area of breast surgery to identify them as more prepared for practice in this area. Additional research should be done to determine where operative and clinical competency minimums for graduating chiefs truly lie.
