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Annals of Surgery Journal Club
Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.
Wednesday, May 02, 2012
May Journal Club

Feast  or Famine?  The Variable Impact of Coexisting Fellowships on General Surgery Resident Operative Volumes. Hanks, JB, Ashley SW, Mahvi DM ,et. al. Annals of Surgery 2011;254:476-485.


In light of work hour regulations, new information is needed to assess the impact of fellowships on general surgery resident operative volume. The authors use case logs submitted by general surgery residents applying  for the 2009 ABS Qualifying Examination  to determine the impact of coexisting fellowships on resident case loads and also to determine if fellowship bound residents begin informal early specialization by performing more procedures in their chosen fellowship during general surgery training . The group chose to study programs with fellowships in colon and rectal surgery, endocrine surgery and vascular surgery and compare to programs without fellowships.

The results show that  programs with endocrine fellowships are associated with increased numbers of endocrine cases performed by the general surgery resident .Residents in programs with colon and rectal fellowships performed and equal  number of colon and rectal cases as residents in programs without these fellowships .  Residents in programs with MIS and vascular fellowships performed fewer MIS and vascular cases than residents in programs with no MIS and vascular fellowships.

In addition, residents bound for fellowship in endocrine, colon and rectal and vascular surgery performed more operative procedures in their future specialty than non-fellowship bound residents. This relationship was not found for residents entering MIS fellowships.


1.       What was the study design?

2.       Are there design flaws that could invalidate or weaken the conclusions?

3.       What is the cause of the general surgery resident increased specialty specific operative volume in programs with endocrine fellowships? Is it do to the fellowship or operative volume at that institution that has resulted in the development of the fellowship?

4.       Do you think the reduction in specialty specific operative volume observed in programs with MIS and vascular fellowships is detrimental to the resident? How would you study this latter question?

5.       Were you surprised by the number of endovascular procedures done by general surgery residents?

6.       If you had a blank sheet of paper and the authority to design a general surgery residency for the 21st century what would it look like in terms  of rotations and duration?

 Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers.

About the Author

Dr. David T Efron
Dr. Efron is an Associate Professor of Surgery, Anesthesiology & Critical Care Medicine and Emergency Medicine at the Johns Hopkins School of Medicine. He is the Director of Trauma and Chief of the Division of Acute Care Surgery (encompassing Trauma, Emergency Surgery and Surgical Critical Care) in The Johns Hopkins Hospital Department of Surgery. He is currently the Vice-Chair of the Maryland State Committee on Trauma. Dr. Efron’s current research interests are within the realm of regulation of inflammatory mediators of septic and post-injury states, particularly focusing on the role that statins play in this milieu. Dr. Efron carries additional interest in traumatic injury from interpersonal violence, measures of violence intensity, and trauma recidivism with an eye to prevention strategies.

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