Does size matter? Our shared cultural heritage in America implies that bigger is better. This is evident in our skyscrapers, automobiles, homes, shopping centers, box stores, and many other aspects of American culture and fashion. Many residency program directors, especially those with small programs, have felt that they may be disadvantaged compared with larger programs regarding Accreditation Council for Graduate Medical Education residency program accreditation. An anonymous survey of surgical program directors asking this specific question was performed. One-half of respondents agreed or were not sure that larger programs had an advantage over smaller programs for accreditation. In addition, program directors were asked about the size of their program, the accreditation length on their most recent review, and their opinion about program size and accreditation performance. The Accreditation Council for Graduate Medical Education mission, by means of their Residency Review Committees, is to “improve health care by assessing and advancing the quality of resident physicians' education through accreditation.” There is a perception that smaller residency programs are more challenged in successfully meeting the program requirements. This may be a reflection of resource constraints or fewer expert faculty and administrative depth.
To obtain nonbiased data, an observational analysis of all 70 independent (nonintegrated) plastic surgery residency programs and Accreditation Council for Graduate Medical Education program accreditation performance was performed. All 70 Accreditation Council for Graduate Medical Education–accredited independent plastic surgery programs were included in the analysis, which included the following:
- Year approved.
- Number of residents per year in the program.
- Total number of residents per program.
- Most recent number of years of approval in the accreditation cycle.
Integrated plastic surgery programs were not included. Data were obtained from the Accreditation Council for Graduate Medical Education (www.acgme.org) Web site for academic year 2010/2011.
There were 17 programs with one resident per year (24 percent), 37 programs with two residents per year (53 percent), 11 programs with three residents per year (16 percent), and four programs with four residents per year (6 percent). Programs with two residents per year were the most common, accounting for 53 percent of all plastic surgery residency programs (chart 1).
Of the 17 programs with one resident per year, 16 had a 3-year approval cycle and one had a 4-year approval cycle, for an average of 3.06 years. Of the 37 programs with two residents per year, 30 had a 5-year approval cycle, one had a 4-year approval cycle, and six had a 3-year approval cycle, for an average of 4.24 years. Of the 11 programs with three residents per year, one had a 6-year cycle, five had a 5-year cycle, one had a 4-year cycle, and four had a 3-year cycle, for an average of 3.45 years. Of the four programs with four residents per year, three had a 5-year cycle and one had a 3-year cycle, for an average of 4.5 years (Fig. 1).
There is a suggested correlation with program accreditation cycle length and program size. Programs with only one resident per year have the shortest accreditation cycle. Larger programs have longer accreditation cycles, which is evidence of support for larger programs. These differences, although very suggestive, were not statistically significant. The number of years of accreditation approval was analyzed as an ordinal categorical variable. The null hypothesis was that there would be no significant relationship between the number of residents per year or total residents and the number of years of accreditation approval. Data were analyzed using ordinal logistic regression with weighted least squares estimation. Frequency tables were analyzed using Fisher's exact test. A value of p ≤ 0.05 was used for statistical significance.
It appears that smaller programs may not be at a statistically significant disadvantage for program accreditation compared with larger programs in plastic surgery. This is comforting and reassuring and validates the fairness of the Residency Review Committee, at least in plastic surgery.
Chris D. Tzarnas, M.D.
Temple University, Philadelphia, Pa.
The author has no financial interest to declare in relation to the content of this article.
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