© 2002 The Society for Surgery of the Alimentary Tract, Inc. 1091-255X/02/$—see front matterPublished by Elsevier Science Inc. PII: S1091-255X(02)00021-5

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Original Articles

Ongoing Deficits in Resident Training for Minimally Invasive Surgery

Adrian Park, M.D., Donald Witzke, Ph.D., Michael Donnelly, Ph.D.

Patient preference has driven the adoption of minimally invasive surgery (MIS) techniques and altered sur-gical practice. MIS training in surgical residency programs must teach new skill sets with steep learningcurves to enable residents to master key procedures. Because no nationally recognized MIS curriculum ex-ists, this study asked experts in MIS which laparoscopic procedures should be taught and how many casesare required for competency. Expert recommendations were compared to the number of cases actually per-formed by residents (Residency Review Committee [RRC] data). A detailed survey was sent nationwide toall surgical residency programs (academic and private) known to offer training in MIS and/or have a leaderin the field. The response rate was approximately 52%. RRC data were obtained from the resident statisticssummary report for 1998–1999. Experts identified core procedures for MIS training and consistently voicedthe opinion that to become competent, residents need to perform these procedures many more times thanthe RRC data indicate they currently do. At present, American surgical residency programs do not meet thesuggested MIS case range or volume required for competency. Residency programs need to be restructuredto incorporate sufficient exposure to core MIS procedures. More expert faculty must be recruited to train

residents to meet the increasing demand for laparoscopy. ( J G

ASTROINTEST

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2002;6:501–509.)

© 2002 The Society for Surgery of the Alimentary Tract, Inc.

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EY

WORDS

: Laparoscopic surgery, minimally invasive surgery, internship and medical residency,surgery, graduate medical education

Cushieri,

1

a visionary and pioneer in the field ofminimally invasive surgery (MIS), once commentedregarding laparoscopy that rarely in surgical historyhave we seen so profound a benefit in patient care inso short a period of time. There is no denying thatthe impact of MIS on patient care since the intro-duction of laparoscopic cholecystectomy in 1987 hasbeen little short of revolutionary. As the number oftechniques performed laparoscopically has explodedover the past decade, patients have benefited fromshorter hospital stays, more rapid postoperative re-covery, and more rapid return to normal activitythan after comparable open procedures. Hospitalstoo have benefited from MIS by increasing surgicalcase volumes while reducing the number of inpatientsurgical beds. Yet, despite the benefits of MIS, manyconcerns about patient safety and well-being andchallenges related to the lack of generally acceptedguidelines have been raised. Because patient demanddrove the adoption of early procedures such as lap-aroscopic cholecystectomy, neither rigorous evalua-

tion nor prospective, randomized comparisons withestablished “gold standards” of care were carried out.By the early 1990s, general surgeons felt compelledto offer their patients laparoscopic cholecystectomyfor fear of otherwise losing referrals for gallstonedisease. These social and market forces placed sur-geons and their patients in an obviously precarioussituation. The neophyte laparoscopist would oftenhave to observe cases or seek training wherever andhowever possible before undertaking these new pro-cedures.

This new field of surgery did not emanate fromacademic medical centers; initially the charge toadopt new MIS techniques was led by private practi-tioners in North America. Academic surgical centershave essentially been playing “catch-up” for the pastdecade. The ideal context in which MIS trainingshould occur is within a surgical residency. Yet oftenresidency training programs encounter the same dif-ficulties in teaching new techniques (and establishingcompetency) that are identified by practicing sur-

Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (oralpresentation).From the Departments of Surgery (A.D., M.D.) and Pathology (D.W.), University of Kentucky College of Medicine, Lexington, Kentucky.Supported in part by an educational grant from Tyco/U.S. Surgical Corporation.Reprint requests: Adrian E. Park, M.D., Department of Surgery, Center for Minimally Invasive Surgery, University of Kentucky, C343, 800Rose St., Lexington, KY 40536-0298. e-mail: apark@pop.uky.edu

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geons. Despite the increasing move toward MIS pro-cedures in surgical practice, no consistent model fortraining the practicing surgeon in new MIS tech-niques or for assessing competency has yet been de-veloped.

2

The purpose of this study was to glean a consen-sus from leading experts in MIS regarding whichprocedures should be incorporated into residencytraining and to determine the number of cases thatwould be necessary to achieve competency in them.

METHODS

A questionnaire related to minimally invasive sur-gery procedures (MISQ) was distributed to two sam-ples. The first sample was drawn from a list of 48surgeons at institutions known to have a program inMIS and/or known as leaders in the field. Twenty-five surgeons who returned their forms (52% returnrate) were included in the study. The second groupwas a convenience sample of 14 individuals who at-tended MIS workshops at the University of Ken-tucky or who were volunteer residents and faculty.The questionnaire used to collect data for the cur-rent study was divided into three sections. The firstsection required respondents to indicate the numberof minimally invasive laparoscopic cholecystectomiesand laparoscopic inguinal herniorrhaphies a surgicalresident must perform as the primary surgeon to befully competent in both. In the second section, re-spondents were asked to indicate how many cases aresident must perform as the primary surgeon to becompetent in other common procedures, given priorcompetency in laparoscopic cholecystectomy andlaparoscopic inguinal herniorrhaphy. The third sec-tion requested that surgeons indicate whether allgeneral surgeons should be able to perform the MISprocedure (“Should it be a core MIS procedure?”).

Data regarding the average number of MIS proce-dures actually performed by residents in 1998–1999were also obtained from the Accreditation Councilfor Graduate Medical Education (ACGME)

SurgeryResident Statistics Summary

by the Residency ReviewCommittee (RRC) for Surgery.

3

The statistics werebased on reports for 936 residents in 240 programsnationally as of November 23, 1999. An updated ver-sion (989 residents in 252 programs as of April 3,2001) of the data matrix was downloaded from theACGME web site.

4

Statistical analyses were com-puted for both sets of data. A third set of data ob-tained from a report published by the Millenium Re-search Group provided estimates of the number ofMIS procedures done nationally by all surgeons for

1998–1999.

5

Data for only five procedures (laparo-scopic appendectomy, laparoscopic antireflux proce-dures, laparoscopic cholecystectomy, laparoscopiccolon/intestinal resection, and laparoscopic inguinalherniorrhaphies) were available to be used in ourcomparisons.

Responses from experts were compared to thosefrom nonexpert surgeons to determine whether dif-ferences would be so large as to preclude using all re-plies from all respondents to characterize MIS pro-cedures. Data regarding the number of MIS proceduresa resident needed to perform to be considered compe-tent were compared for the two groups using

t

tests.Similarly, the number of respondents in each groupwho indicated whether a procedure should be core ornot was compared using

�

2

analysis. Because two re-spondents made a “Yes” and a “No” response to aMIS procedure, the ratings were designated as “Yes”only for comparisons involving frequency.

Data from the RRC reported for both periodswere compared statistically to MISQ data using

t

tests. Bonferroni corrections were made for all statis-tical comparisons, using 50 as the number of vari-ables compared for the entire study. This correctionadjusts the alpha level required for a

P

value to besignificant to reduce the probability that the findingwas a chance result because of the number of signifi-cance tests that were calculated. Where statisticalsignificance was obtained after the Bonferroni cor-rection, Cohen’s effect size was calculated for eachcomparison to determine the “importance” of thesignificant finding.

A one-way analysis of variance was used to deter-mine if there were significant differences in the meannumber of times the various procedures needed tobe performed for competency. Although a within-groups design would normally have been appropriateto test the differences among the means, a between-groups design was used instead. The impact of thisdesign change was to make our testing of the null hy-pothesis more conservative; that is, we increased theprobability that we would accept the null hypothesiswhen it was, in fact, false. The Games-Howell posthoc test was used to identify the exact pattern of dif-ferences among the means. This method was chosenbecause it can be used with unequal numbers of sub-jects and heterogeneous variances.

6

Both of theseconditions were present in our data.

Single-group

t

tests for proportions were used todetermine if procedures were judged “core” by thegroup as a whole.

7

The proportion of MIS surgeonsdesignating a procedure as core was compared to ahypothetical population mean of 0.5, the expectedmean if no consensus emerged. If the proportion wassignificantly higher than 0.5, we considered it to be a

Vol. 6, No. 32002 Deficits in MIS Resident Training

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core procedure. If the proportion was significantlylower than 0.5, it was not considered core.

RESULTSExperts vs. Nonexperts on theMIS Questionnaire

Comparisons of both groups’ estimates of thenumber of MIS procedures required for competencyyielded no significant differences after the Bonfer-roni correction. Although not significant after thecorrection, means (and standard errors of the mean)for the two groups for laparoscopic inguinal hernior-rhaphies were 42.8

�

4.1 and 25.7

�

3.5 (

t

�

2.79,df

�

37), respectively. Although estimates of thenumber of procedures required to be competent inlaparoscopic cholecystectomy (n

�

200) and laparo-scopic inguinal herniorrhaphies (n

�

100) made byone expert might be considered outliers, we made noadjustment. The means, standard errors of the mean,and numbers responding for laparoscopic cholecys-tectomy and laparoscopic inguinal herniorrhaphiesare displayed in Table 1. Data for the number ofprocedures required for competency for the remain-der of the procedures are also presented in Table 1.Note that sample sizes varied because of missingdata. None of the

�

2

analyses resulted in significantdifferences between the two groups regarding thepercentage of respondents indicating that the proce-dure should be considered as core in training resi-dents.

Because there were no significant differences in theestimates of experts and nonexperts of the number oftimes a procedure needed to be performed for compe-

tency, the two sets of estimates were combined in thefollowing analyses. A between-groups analysis of vari-ance was performed to determine if there were overallsignificant differences in the frequency with which thevarious procedures needed to be performed to achievecompetency. Laparoscopic cholecystectomy and lap-aroscopic inguinal herniorrhaphies were not includedin this analysis, because they were assumed to be thefirst procedures to be learned and thus required asteeper learning curve. The analysis of variance was sig-nificant (F

�

12.90, df

�

10, 394;

P

�

0.0001). TheGames-Howell post hoc test was used to determine theexact pattern of differences. The number of times thevarious procedures needed to be performed could bedivided into three levels. The means needed for compe-tency in the relatively high-frequency laparoscopic pro-cedures are bariatric (33.2), colon (27.6), and antireflex(24.0). Biliary (21.3), gastric (20.0), and adrenal (17.2)are at the second level and need to be performed be-tween 17 and 21 times for competency. The lowestgroup includes spleen (14.8), anterior/incisional hernia(12.9), gastrostomy/jejunostomy (10.8), diagnostic pro-cedures (10.8), and appendectomy (10.6), which need tobe performed between 11 and 15 times for competency.

Experts vs. Residency Review Committee Procedure Report

Comparison of experts’ estimates of the numberof procedures a resident must perform to be compe-tent with the actual number performed by residentsat programs reviewed by the RRC reached signifi-cance for all 10 of the procedures listed for 1998–1999.

3

Nine of the 10 procedures reached signifi-

Table 1.

Number of procedures as primary surgeon required for competency and number given competency at laparoscopic cholecystectomy and inguinal herniorrhaphy (mean

�

SEM)

Survey respondents

Procedures Experts N Nonexperts N All N

Laparoscopic inguinal herniorrhaphy (LIH) 42.8

�

4.1 25 25.7

�

3.5 14 36.7

�

1.6 39Laparoscopic cholecystectomy (LC) 40.4

�

7.2 25 30.2

�

4.7 14 36.7

�

4.9 39Given competency at LIH and LC

Laparoscopic bariatric surgery 35.3

�

6.6 19 29.5

�

4.5 11 33.2

�

4.4 30Laparoscopic colon/intestinal resection 29.4

�

3.9 25 24.2

�

4.1 13 27.6

�

2.9 38Laparoscopic antireflux procedures 26.2

�

2.4 25 19.6

�

4.0 13 23.9

�

2.1 38Laparoscopic biliary surgery 22.5

�

3.4 24 19.0

�

2.4 12 21.3

�

2.4 36Laparoscopic gastric surgery 19.4

�

2.3 24 21.3

�

3.5 12 20.0

�

1.9 36Laparoscopic adrenalectomy 16.4

�

1.5 25 18.8

�

3.4 13 17.2

�

1.5 38Laparoscopic splenectomy 15.0

�

1.5 25 14.4

�

2.0 13 14.8

�

1.2 38Laparoscopic anterior/incisional hernia 13.0

�

1.4 25 12.7

�

2.5 12 12.9

�

1.2 37Diagnostic laparoscopy 11.4

�

2.2 25 9.5

�

2.2 13 10.0

�

1.6 38Laparoscopic appendectomy 11.2

�

0.9 25 9.4

�

1.6 13 10.6

�

0.8 38Laparoscopic gastrostomy and jejunostomy 10.1

�

1.0 25 12.0

�

2.5 13 10.8

�

1.6 38

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Park et al. Gastrointestinal Surgery

cance for comparisons of the updated data reportedon April 4, 2001 for programs reporting in 1998–1999.

4

All differences that were significant (after theBonferroni correction) yielded large effect sizes aslabeled by Cohen. The single laparoscopic proce-dure failing to reach significance in the 2001 RRCreport was for antireflux procedures.

4

Note that inall comparisons but one (laparoscopic cholecystec-tomy), MIS experts indicated that residents neededto complete significantly more laparoscopic proce-dures than the RRC-reported residents were actuallydoing for both reporting periods.

3,4

In contrast, resi-dents were performing almost twice as many laparo-scopic cholecystectomies as experts thought wererequired. The differences between what the MIS ex-perts estimated as the minimum number requiredand what residency programs reported to the RRCin 1998–1999 are displayed in Table 2. Five proce-dures, (laparoscopic bariatric surgery, laparoscopicgastric surgery, laparoscopic adrenalectomy, laparo-scopic splenectomy, and laparoscopic anterior/inci-sional herniorrhaphy) included in the MISQ werelisted as having an average of one or fewer casesacross residency programs in the 2001 RRC report.

4

Experts vs. Procedures MIS Performed in1998–1999

Searching for published data regarding the totalnumber of MIS procedures performed revealed onlyone source. We have summarized the MillenniumResearch Group estimates

5

provided for laparoscopicinguinal herniorrhaphy, laparoscopic cholecystectomy,laparoscopic colon/intestinal resection, laparoscopic

appendectomy, and laparoscopic antireflux proce-dures in Fig. 1. Note that although the data sets aredifferent in scale, comparing proportions within datasets allows one to see the difference in relative mag-nitude among the procedures.

In the MISQ, the MIS surgeons were also askedto judge whether each of 11 procedures was core.The proportion judging a procedure as core wascompared to a proportion of 0.5, the expected pro-portion if no group consensus emerged. Seven of theprocedures (diagnostic laparoscopy, laparoscopic an-tireflux procedures, laparoscopic appendectomy,laparoscopic gastrostomy and jejunostomy, laparo-scopic anterior/incisional herniorrhaphy, laparo-scopic biliary surgery, and laparoscopic colon/intes-tinal resection) were judged to be core (all

P

�

0.001),laparoscopic bariatric surgery and laparoscopic ad-renalectomy were considered not core (both

P

�

0.01), and there was uncertainty about whether ornot laparoscopic splenectomy and laparoscopic gas-tric surgery were core.

DISCUSSION

Competency, as Trunkey and Botney

8

have pointedout, is a concept that defies easy definition. For sur-geons, in addition to varying degrees of medical knowl-edge, judgment, and inductive reasoning, competencyrequires visiospatial facility, manual dexterity and, ofcourse, experience. In an earlier study,

9

we tested thehypothesis that judgment was a critical feature ofcompetent surgical performance. Our data demon-strated the need for clinical judgment in the perfor-

Table 2.

Data for the number of procedures required for competency

Data sources

Procedures Experts N RRC N

Laparoscopic inguinal herniorrhaphy 42.8

�

4.1 25 7.6

�

0.3 989Laparoscopic cholecystectomy 40.4

�

7.2 25 84.0

�

1.1 989Laparoscopic bariatric surgery 35.3

�

6.6 19 0 989Laparoscopic colon/intestinal resection 29.4

�

3.9 25 1.9

�

0.1 989Laparoscopic antireflux procedures 26.2

�

2.4 25 8.5

�

0.3 989Laparoscopic biliary surgery 22.5

�

3.4 24 0.9

�

0.1 989Laparoscopic gastric surgery 19.4

�

2.3 24 0.1

�

0.0 989Laparoscopic adrenalectomy 16.4

�

1.5 25 0 989Laparoscopic splenectomy 15.0

�

1.5 25 1.0

�

0.0 989Laparoscopic anterior/incisional hernia 13.0

�

1.4 25 0 989Diagnostic laparoscopy 11.4

�

2.2 25 4.7

�

0.1 989Laparoscopic appendectomy 11.2

� 0.9 25 5.4 � 0.2 989Laparoscopic gastrostomy and jejunostomy 10.1 � 1.0 25 1.4 � 0.1 989

Experts’ estimates of the number of procedures as primary surgeon required for competency for laparoscopic cholecystectomy and laparoscopicinguinal herniorrhaphy and number of procedures as primary surgeon required for competency in laparoscopic cholecystectomy and laparo-scopic inguinal herniorrhaphy versus number of procedures reported for all residency programs in the April 2001 RRC report.

Vol. 6, No. 32002 Deficits in MIS Resident Training 505

mance of laparoscopic skills. This fact may attenuatethe learning curve of a skill to a degree that could notbe predicted from the purely technical aspects of thatskill.9

Surgical experience is acquired by both direct andindirect means. Of the many factors that contributeto a surgeon’s experience, one that is easily quantifi-able is the number of times a surgeon has performeda particular procedure. Although case volumes donot tell the whole story of a surgeon’s competency,the American Board of Surgery uses this measure toset minimum normative standards for defined cate-gories of surgical procedures. These numbers are inturn applied by the RRC in assessing surgical resi-dency training programs for accreditation. Althoughthe ACGME has recently (1999) endorsed six addi-tional areas of general competency deemed applica-ble to all physicians, there are currently no univer-sally accepted measures for any of these suggestedareas of competency.3 At present, in the surgical spe-cialties the number of cases performed by a residentis the most important and widely accepted measureof competency.

A number of forces are currently pressuring thehealth care training systems in the United States toshift their objectives from being process oriented tobeing outcome oriented. One force compelling thischange is the report from the Institute of Medicine10

on medical errors. In looking at a comprehensiveapproach to reducing medical errors and improvinghealth care, the Institute states that no one changewill alter the pattern of nonresponsiveness of thehealth care system. One of the key changes the Insti-

tute does address is “identifying and learning fromerrors.”10 They recommend that “health professionallicensing bodies should implement periodic reexami-nations and relicensing of doctors . . . based on bothcompetence and knowledge of safety practices . . .”10

The shift to training outcomes as a basis for accredi-tation initiated by the ACGME in conjunction withthe American Board of Medical Specialties will havedirect consequences for MIS training programs. Theshifts from process to outcome also carries with it aseries of methods (an assessment “toolbox”) for eval-uating the effectiveness of training in terms of resi-dent performance. Typically, evaluation is character-ized by one or more methods that will reliably andvalidly yield scores that can be used to judge compe-tency and provide sufficient objective information tocorrect flawed performance by a resident.

IMPLICATIONS

Our data show little disagreement among theexperts as to the number of cases required for com-petency (for the various procedures), or even a sig-nificant difference between experts and nonex-perts. On the other hand, the disparity between thenumber of cases recommended by experts and theactual national average number of those cases per-formed through the course of a surgical resi-dency3,4 is remarkable. Furthermore, the nationalaverage number of cases per graduating surgeon isone or less3,4 for four procedures (laparoscopic gastros-tomy and jejunostomy, laparoscopic anterior/inci-

Fig. 1. Experts (N � 25) and Millennium Research Group (MRG) estimates of minimally invasive surgi-cal procedures performed in 1998–1999.

Journal of 506 Park et al. Gastrointestinal Surgery

sional hernia, laparoscopic biliary surgery, and laparo-scopic splenectomy) that MIS experts consideredcore surgical residency procedures.

It might be argued that this “crisis in training” is afabrication by those proponents of MIS who over-state the real world impact/growth of these proce-dures. It is very difficult to access current data on thenumber of laparoscopic procedures being performednationally or to establish what proportion of specificprocedures (e.g., colon resection) is performed lap-aroscopically. The Millennium Research Group5 hasrecently documented current case volumes and pro-jected growth (positive or negative) of various MISprocedures. The Millennium Research Group studynotes that cases of MIS are on the rise and that mostprocedures, with the exception of laparoscopic in-guinal herniorrhaphy, are projected to grow over thenext few years at annual rates varying from 3% to15%.5 These procedures are clearly here to stay, asevidenced by growing patient demand for them.Therefore concerns for the limitations of surgicalresidency training should not be confined solely tothose proponents of MIS.

To bridge the considerable chasm between therecommended number of MIS cases and the actualMIS training experience of graduating surgeons, cer-tain challenges must be met. Given the call frommultiple sources for competent performance of phy-sicians, we must ask how to maintain current trainingquality while implementing broader training in MIS.In response, bold steps need to be considered andtaken. There are several reasons why MIS experiencefor surgical residents is lacking, particularly at aca-demic medical centers. First, most academic surgicaldepartments across the country are still lagging be-hind the (surgical) private practice community interms of embracing MIS procedures. Many academicmedical centers have only recently recognized theneed to establish centers or services in MIS. Second,because attempts at reassigning existing faculty inthe hope of developing “homegrown” programs inMIS have often met with failure, emphasis needs tobe placed on the recruitment of fellowship-trainedlaparoscopic surgeons to help build MIS into surgi-cal training programs. Third, support for the train-ing of existing faculty in these new techniques isneeded.

Another challenge facing surgical training pro-grams is integrating MIS into an already crowdedpostgraduate curriculum. None of the demands fortraining in open surgery have lessened. Because con-version to open surgery is the solution of choicewhen unanticipated intraoperative complications arise,MIS training must be built on the traditional ground-ing in open surgery. Even so, more time needs to be

reserved for early and repeated resident exposure toMIS. This may occur on specialized services, or byintegrating (with appropriate faculty recruitmentand retraining) MIS procedures into established ser-vices.

Added to the difficulty of integrating MIS intoresident rotations is the growing cost of training sur-geons in the operating room. This expense (now es-timated at $48,000.00 per graduating resident)11 in-dicates that more training needs to move out of theoperating room. Fortunately, the acquisition of es-sential laparoscopic skills can be facilitated by the useof mechanical and computer-based simulators. Scottet al.12 have demonstrated that the skills acquired bypracticing simple tasks in a laparoscopic trainer canbe transferred to the operating room. The experts inthis study indicated that a rather large number ofprocedure-specific experiences are required for com-petency; could this number be reduced if the skillsneeded for MIS were sufficiently honed before theresident entered the operating room? If the residentspends enough time in practice to evidence an ade-quate level of competency, moving from simulationto an actual patient becomes an efficient and man-ageable step. Consequently, residency programs willneed to allocate time for inanimate or skills labora-tory training, as well as provide accessible equipmentwithin reasonable proximity to the operating roomand with extended hours of operation.

CONCLUSION

Clearly, the problem of training programs that donot meet training needs is not confined to the fieldof MIS. Although a full analysis of such problemsfacing all surgical specialties is beyond the scope ofthis report, it is hoped that some of the issues raisedand suggestions made to address the shortcomings oftraining in MIS may also find application in other ar-eas of surgical training. We felt the need to focus at-tention on the inadequacy of resident training inMIS because much is at stake for the general sur-geon. The field of general/abdominal surgery hasevolved considerably over the past few years. Pa-tients are increasingly “voting with their feet” forminimally invasive procedures in the treatment ofgastrointestinal and other abdominal disorders. Thisis the future of general surgery. If these procedurescontinue to fall into the domain of the (relativelyfew) fellowship-trained minimally invasive surgeons,then general surgery faces the very real risk of “de-volving” to gallbladder, hernia, and breast surgeryalong with some miscellaneous procedures.

Current MIS training, as reported by American

Vol. 6, No. 32002 Deficits in MIS Resident Training 507

surgical residency programs, does not include all ofthe MIS procedures that experts in the field considercore to surgical residency training. For most coreprocedures, residents do not carry out the number ofthose procedures experts say are needed to achievecompetency, according to American surgical residencyprogram reports. The solution to this dilemma will bemultifaceted, but must include strategies for the re-cruitment of fellowship-trained laparoscopic facultyto academic medical centers and American surgicalresidency programs, as well as early and repeated ex-posure to MIS clinical rotations. More emphasismust be placed on the acquisition of surgical skillsoutside the operating room by the use of inanimatesimulators. Finally, surgical educators must be pre-pared to explore and harness new technology (virtualreality, imaging, haptics, the Internet, etc.) for thefuture training of our surgical colleagues.

REFERENCES

1. Cushieri A. Whither minimal access surgery: Tribulationsand expectations. Am J Surg 1995;69:9–19.

2. Rogers DA, Elstein AS, Bordage G. Improving continuingmedical education for surgical techniques: Applying the les-sons learned in the first decade of minimal access surgery.Ann Surg 2001;233:159–166.

3. Residency Review Committee for Surgery. Residency statis-tical analysis report. In Program Data: Defined Categories.Accreditation Council for Graduate Medical Education,1999.

4. Residency Review Committee for Surgery. Surgery ResidentStatistics Summary (Accreditation Council for GraduateMedical Education web site). Available at http://www.acgme.org/RRC/reports/GSRptC19992000.pdf.

5. Millennium Research Group. US laparoscopy 2000 (ReportUSLAP00). Toronto, Ontario: Millennium Research Group,2000.

6. Kirk RE. Experimental Design: Procedures for BehavioralSciences, 3rd ed. Belmont, California: Wadsworth Publish-ing, 1994.

7. Hayes WL. Statistics, 5th ed. Ft. Worth, Texas: HarcourtBrace, 1994.

8. Trunkey DD, Botney R. Assessing competency: A tale oftwo professions. J Am Coll Surg 2001;192:385–395.

9. Donnelly MB, Witzke DB, Mastrangelo M, Park A. Theeducational implications of the importance of clinical judg-ment in performing laparoscopic skills. Poster presented atSAGES 2000.

10. Kohn LT, Carigan JM, eds. To err is human: Building asafer health system. Washington, D.C.: N.A. Press, 1999.

11. Bridges M, Diamond DL. The financial impact of teachingsurgical residents in the operating room. Am J Surg1999;177:28–32.

12. Scott DJ, Bergen PC, Rege RV, Laycock R, Tesfay ST,Valentine RJ, Euhus DM, Jeyarajah DR, Thompson WM,Jones DB. Laparoscopic training on bench models: Betterand more cost effective than operating room experience? JAm Coll Surg 2000;191:272–283.

DiscussionDr. G. Branum (Harrisonburg, VA): I was won-

dering whether in the course of your study you wereable to gather any statistics from minimally invasivefellowship programs and whether all of the fellow-ship programs are meeting all of these levels in areasof competency?

Dr. A. Park: That is an interesting question andprobably warrants a follow-up study. Although manyof the respondents, in fact, ran fellowship trainingprograms, our focus was solely on the resident train-ing experience.

Dr. L.W. Way (San Francisco, CA): I have twoquestions. First, if you exclude such things as bariatricsurgery and adrenalectomy (and maybe Heller myo-tomy might be on that list) from the course of studyfor general surgical training, then we really do nothave any formal training for those procedures. I thinkthat, in general, the profession accepts that training inbariatric surgery is part of a general surgical educationtoday. So that creates a special problem of how youare going to deal with the excluded group.

My second question concerns the problem of themismatch between the ultimate intended careers of thelearners and the pool of available teaching material.

We continue, in general surgery residency programs,to train people, at the time they are chief residents, todo things that they never intend to do in the future,and we find that in this particular instance there is justa shortage of training material. If we could resolve thisissue of mismatch, it seems to me that this might beanother way to approach this problem.

Dr. Park: I will respond to your second questionfirst. One of the points that we make in our article isthat lest you think that this is a shortage or crisis fab-ricated by proponents of minimally invasive surgery,we very diligently sought data that would help us de-termine whether the training material—that is, theclinical base or volume, if you will—was growing ornot, and whether this is a real or simply a contrivedproblem.

Again, this is addressed in more detail in our re-port, but one commissioned study that was publishedlast year looked at the growth rates of these variousprocedures and, with the exception of one interest-ingly, laparoscopic inguinal herniorrhaphy—which iscurrently in the negative growth phase and is pro-jected to remain so for the next year or two, everyother procedure is projected to grow from 3% to 15%

Journal of 508 Park et al. Gastrointestinal Surgery

per annum, including all of the procedures that we in-cluded in our study, for the foreseeable future. So Ithink we are focusing on areas where there is patientdemand and clinical need.

Dr. M.T. Dayton (Salt Lake City, UT): I do notthink the phenomenon you have described here islimited to minimally invasive surgery. For example,if you take into consideration “open” surgical cases,such as thoracic procedures, ENT procedures, andmaybe some of the more complicated biliary and he-patic cases, many of the residents in our programsfinish their training without performing an adequatenumber of operations to really be described as com-petent. So this is really not a phenomenon that islimited to the domain of minimally invasive surgery.

Dr. Park: This could apply to other areas as well.Obviously, again, we focused specifically on mini-mally invasive surgery. This is a specified field with amuch shorter history that has brought our attentionto the problem. But certainly this could apply on abroader basis.

Dr. C. Pellegrini (Seattle, WA): I believe the an-swer is simple. If you want to be practical today inthe United States, you will have to either close anumber of residency programs and just use a few thatwill have a sufficiently high volume to accomplishthe things that you plan or it will be necessary tosimply extend the training of a surgeon, as is done inEurope, for 10 years or 20 years, neither of which so-ciety in this country would be willing to do. So if youwant to be practical, you would have to stay with thenumbers that we have right now. That is my per-sonal opinion. I am not speaking for the Accredita-tion Council for Graduate Medical Education.

But my question is, were these surgeons in-structed as to what might be an outcome to look forwhen they decided that the number of cases shouldbe 30 and not 15 or 20? Was it when time plateaus orwhen complications plateau? Why did they decidethat this was the number of operations that a personneeded to be trained? Second, did you ask them whatthe number of operations per year might be that asurgeon might have to perform throughout his orher career in order to remain competent? As to theAmerican Board of Medical Specialties part of theoutcomes projects that you alluded to, this boardrequires that for recertification purposes or mainte-nance of certification, a person will have to meetthese criteria. It is a remarkable comparison if, as youstated today, 30 colectomies would be required com-pared to the number that is currently required for re-certification, which is eight.

Dr. Park: No, we did not ask about the ongoingprocess. That is a good point. The respondents toour survey were not asked to elaborate upon the rea-

sons they determined a particular “number of cases”conferred competency for a specific procedure. Thenumber may have reflected a time or complicationsplateau but more likely was a global assessment orrating.

Dr. Pellegrini: How about maintenance?Dr. Park: No, we did not look at that either.

Again, we focused, just as in a snapshot, on the sub-ject of residency training.

Dr. L. Rikkers (Madison, WI): My comment isalong the line of Dr. Dayton’s in that with indexcases that are used in surgery, including laparoscopicsurgery, there are not enough cases nationwide totrain everyone who is being trained. So that is aproblem we need to address.

There is another element to this, however, andthat is the transference of skills. For example, if asurgeon has the opportunity during training to per-form 20 major liver resections but happens not toencounter any proximal bile duct cancers, he or sheis going to be able to learn how to handle a proximalbile duct cancer much better if he or she has a broadexperience in liver resection.

I would ask you, how about this transference as itrelates to the field of laparoscopy? For example, ifyou are in a program that is very rich because there isa large hematology unit on the medical side in doingelective laparoscopic splenectomies, do trainees wholearn how to perform that operation well need asmany cases to learn how to perform a laparoscopicadrenalectomy after they become proficient in lap-aroscopic splenectomies? I think that is the addi-tional factor of how skills are transferred from oneprocedure to another or how persons are able tolearn another procedure quite easily if they have per-formed a procedure that is fairly similar a number ofother times.

Dr. Park: The purpose of this study was topresent a “snapshot view” and to basically raise issuesthat would instigate discussion. The issue of transferof training is a very important one, and we have ad-dressed in the manuscript not only transferring skillsfrom laparoscopic splenectomy to adrenalectomy,but we believe increasingly that skills can be acquired(transferred from) outside the operating room. Thereare several centers across the country and efforts atuniting focus across the country right now on the de-velopment of some of these psychomotor skills, spe-cifically in this area, such that the number of proce-dures that need to be performed in the operatingroom can drop precipitously from 30 colectomiesdown to a much more manageable number. So weagree very definitely that there is opportunity fortransfer, not just from other techniques but fromnonoperative training experiences.

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Dr. B.D. Schirmer (Charlottesville, VA): I have acomment and then another question, both of whichecho points made by Dr. Rikkers. The comment Iwant to make is that I do not think we should be suchalarmists about this situation; if you look at the num-bers reported by the RRC 5 years ago, the meannumber of Nissen procedures being done was oneand the hernia repairs was down around one or two.So within 5 years we have increased those numberssignificantly. Thus, I think it is very clear that theproblem is that we as faculty at institutions whereresidents are being taught are just not seeing as manycases, and if we were seeing more of these cases, wewould have the residents performing more opera-tions. So I think we are making some improvements,but clearly it is a very slow process.

My second question again echoes the question ofwhether you asked the experts if they had a number ofadvanced cases as an aggregate. In other words, I per-

sonally believe that if residents are taught to perform15 or 20 Nissen procedures, then they can go on andperform a laparoscopic gastric resection much moreeasily, and, similarly, if they can do a colectomy, thenthey can probably do a Nissen fundoplication withoutmuch difficulty because of the skills they have ac-quired. Did you have any sort of survey questionwhere you asked about the minimum number of ad-vanced cases to indicate advanced skills?

Dr. Park: The survey contained a question re-garding the number of cases required to establishcompetency in basic procedures i.e., laparoscopiccholecstectomy and laparoscopic inguinal hernior-rhaphy. Once these competencies were assumed therespondent then indicated how many cases of otherprocedures were needed. So each procedure wasthen taken as an isolated case once a basic level oftraining had been established.