For 2013, for the required case or procedure types, residents performed from 1.6 times (pediatrics aged <12 years) to 4.5 times (epidural) the ACGME minimum number. For 2014, depending on the requirement, residents performed from 1.5 times (pediatrics aged <12 years) to 4.2 times (epidural) the ACGME minimum number.
There were 7 residents in 2013 and 2 residents in 2014 who did <50% of the class average for pediatric < 3 months, whereas there were 2 residents in 2013 and 1 resident in 2014 who did >200% the class average.
For cardiac cases, 7 residents in 2013 (none in 2014) had <50% of the class average and 2 had >200% the class average (none in 2014). For nerve blocks, 2 residents in 2013 and 1 in 2014 reported <50% the class average, whereas 1 in 2013 had >200% the class average.
Variability in number of cardiac cases was correlated with the number of cardiac rotations the residents did (Fig. 4). A greater number of pediatric (r = 0.542, P < 0.0001) and obstetric (r = 0.556, P < 0.0001) rotations was also correlated with more of those case types. There was variability in peripheral nerve blocks despite every resident doing a single 1-month rotation.
There was 1 resident in 2013 and 4 residents in 2014 who did <50% of the class average for new pain evaluations, whereas there were no residents in 2013 and 2 residents in 2014 who did >200% the class average for new pain evaluations. In 2013, on average, 78% (SD, 11%; median, 77%; range = 55%–100%) of total patients logged in were OR cases, and 89% (SD, 3%; median, 89%; range = 82%–95%) of all OR cases were general anesthetics. In 2014, on average, 76% (SD, 8%; median, 78%; range = 55%–92%) of all patients logged were OR cases, and 89% (SD, 3%; median, 90%; range = 82%–94%) of OR cases were general anesthetics.
Although most anesthesia residents in this training program recorded similar numbers of cases, there are a few residents in each of the 2 graduating classes who had many more cases than their peers, and there are a few residents who had many less cases than their peers. In addition to variability in the total case experience, there was also variability in the number of cases and cases required for the required categories. This variability could have been because of several factors including (1) once a resident reaches the minimum requirements for case and procedures, they may be less motivated to log more of them, (2) lack of accepted guidelines for when to log cases (e.g., some residents log cases when a resident relieves another resident, but not all residents do this), (3) number of research months varies by trainee and reduces caseload because the trainee is out of the clinical environment, or (4) some residents may be more meticulous in recording of every case and procedure.
Approximately 70% of residents had caseloads between 75% of the class average and 150% of the class average. A few residents in each of the 2 graduation classes had many more (which we arbitrarily defined as 1.75 times the class average) pediatric cases or many more cardiac cases than their peers. For cardiac anesthesia, some residents completed as many as 6-month long rotations, whereas many residents completed the required minimum of 2 months. It may be that a few residents are able to customize their clinical training experience by choosing to do more elective months on rotations of particular interest resulting in many more of a particular clinical specialty case type compared with the class average. One or 2 residents in each graduating class did more than twice the class average of pediatric anesthesia.
The variability in case load that we observed is important, because it is a reminder that training programs cannot be evaluated simply by the average number of cases performed by the trainee. That summary data may not indicate whether a couple of residents are at the 90th percentile in cases number experience and another may be at the 10th percentile of experience.12
Although focusing on a particular clinical subspecialty during residency is not a formal pathway within our training program, the 2010 Carnegie study on medical education recommends creating individualized learning pathways.13 Depending on the case and volume mix at different institutions and training programs, house staff may be able to focus on some subspecialties if there is flexibility in the elective rotation schedule. As another example of residents customizing their training, a few residents in each cohort had 5 to 9 research months in the 3-year residency.
There are other published studies of case log analyses, mostly in the surgical disciplines. These studies have found that operative volume has decreased, increased, or stayed the same depending on the type of surgery.14 For example, a study of spine surgery procedure volumes determined that in orthopedic and neurosurgery residency training programs, caseload varies both within and among specialties.15 A few studies examined general surgery and showed that residents had fewer total cases,16 fewer pediatric surgery cases,17 and fewer open abdominal procedures18 after implementation of duty hour restrictions. Surgery resident comfort level with procedures was associated with performing more procedures.19 None of these studies specifically evaluated differences in case experience by residents within the same training program. The American Board of Anesthesiology does not consider case log reports for certification, whereas some surgical specialties do use them for their certification process.a,b
Future studies need to examine what fraction of case variability is because of differences in self-report and how much is related to residents choosing different clinical electives. Even though some residents in our study reported >1800 cases in 36 months of residency, it is possible that there were other additional cases and procedures that were not entered. For example, it may be that residents are biased toward entering those that are required and not entering more routine cases. As a result, the actual true case experience may be underreported because of this self-report bias. Other studies have demonstrated the potential for inaccuracies and discrepancies.20–22 Discrepancy between self-report and actual cases by surgery residents equaled 20%. Another study found that more than half of neurology residents entered less than half of their cases, and many residents indicated the case log system interfered with their education and patient care.21 Emergency medicine studies estimated that manual self-reporting results in capturing only 60% of actual clinical experience.c23
Given our findings and other investigators’ findings, it is likely worthwhile for residency leadership to establish guidelines on entering cases so that there is more uniformity in understanding and practice. These guidelines would need to specify among other things, for instance, that the thoracic case example should be entered once with the 3 required elements (thoracic, epidural, and nerve block) checked off on the website questionnaire and not entered 3 times separately with each required element (as we have heard is possible anecdotally). If various counted elements of a thoracic case were entered as separate patients, this would skew the total number of patients, but not change the count of the tracked elements, which form the primary basis of the case-tracking evaluation.
Education and instructions regarding case logs should include guidelines about logging cases with handoffs. The ACGME Anesthesiology FAQd does provide some guidance. For example, for the question, “Can two residents/fellows individually count the same case if they both participate in the patient’s care?” the document states: “If two individuals were involved in the majority of a major case (such as a liver transplant), including the most significant portions, each resident, or a resident and a fellow, can receive credit for the case by entering it into the Case Log System. When one resident or fellow completes a case for another, only the individual involved in the most significant aspects of the case, or the majority of the procedure, should record credit for the case.” Although these FAQs exist, it is not clear how widely disseminated they are to residents.
Rubrics on how to categorize particular cases such as new pain evaluations are also needed. For example, some residents may log a consult for analgesia in the postanesthesia care unit as a new pain evaluation, whereas others may only log a pain consult when on the acute pain rotation. In our study, some residents recorded less than half the class average for new pain evaluations, and some residents had >200% the class average. Another example of a possible area of documentation confusion for the resident is if a patient receives a nerve block by resident Smith in the preoperative area and resident Jones takes care of the patient in the OR. Sometimes resident Jones may report that the case had a nerve block instead of the resident performing the block, so there would be double counting.
Inaccuracies are also likely to occur when the time gap is longer between performing the case and entering the data. Some residents may feel pressure to report high case log numbers because of the minimum case number requirements and scrutiny by residency programs, the Resident Review Committee, and prospective employers. Because of the flaws with self-reporting, several programs have used innovative ways to improve the accuracy of reporting.22 It may be that applications for the smart phone may make it easier for house staff to enter cases. We are starting a project to extract cases and procedures directly from the electronic medical record.
There are no standards beyond the minimum case requirements as to how many other cases and procedures an anesthesia resident should do. Also, currently, the ACGME database does not collect the types of patients and conditions residents care for in the intensive care unit, preoperative clinics, or postanesthesia care unit, all of which are required rotations. Residents may enter procedures such as invasive lines or nerve blocks performed on those patients in the ACGME online database as another source of variability in procedure numbers.
Other items may be beneficial to collect experience on to better quantify a resident’s training. In fact, hospital privilege applications for new graduates may ask for confirmation of cases performed not currently in the ACGME data collection system. Actual examples of such requests received by our program include the resident case total for management of cardiac arrest, diagnostic tap, spinal drain, blood patches, acupuncture, fluoroscopy, spinal steroid injection, and transversus abdominis plane block.
Residents who recorded having more pediatric cases, nerve blocks, vaginal deliveries, and more pain evaluations had higher total case counts. This is likely partly explained because there is a potential for more cases in these areas in our training program. In contrast, the upper number of possible cardiac, thoracic, neurosurgery, and major vascular cases is more limited. Hence, those case types were not associated with higher total case counts.
Although the ACGME has minimums for 15 common anesthesia procedures required for resident graduation, there are no maximums stipulated above which a resident need not perform anymore. The relationship between case volume and achievement of milestones deserves further study. Although the overall case totals for the residents studied were similar to national averages as reported on the ACGME website, 1 limitation of this study is that case logging practice at 1 residency may not be representative of programs around the country.
In conclusion, analysis of resident case logs in our large anesthesiology residency program reveals variability in total required cases and procedures. Lacking objective data about cases performed versus cases reported by the house staff, we can only speculate about the causes of the variability. Some variability may be because of hazards of self-reporting and resulting bias, whereas some of the variability may be because of house staff choosing to complete different electives, thereby customizing their training even if there are no formal pathways. More research is needed to better understand which anesthesia cases and procedures are not being logged in each residency and nationally. More formalized and comprehensive guidelines to standardize case logging practices may be especially useful because employers ask for these data and because ACGME increasingly evaluates residencies based on the data collected electronically.
a ABPlSurg.org. Available at: https://www.abplsurg.org/ModDefault.aspx?ReturnUrl=%2f. Accessed June 23, 2015.
b The American Board of Anesthesiology. Available at: http://www.theaba.org/Home. Accessed June 23, 2015.
c Lee JS, Sineff SS, Sumner W. Validation of electronic student encounter logs in an emergency medicine clerkship. In: Proceedings of the AMIA Symposium. American Medical Informatics Association, 2002:425. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2244433/. Accessed April 16, 2015.
d https://www.acgme.org/acgmeweb/Portals/0/PDFs/FAQ/040_anesthesiology_FAQs_07012014.pdf. Accessed June 23, 2015.
1. Grasberger RC, McMillian TN, Yeston NS, Williams LF, Hirsch EF. Residents’ experience in the surgery of trauma. J Trauma. 1986;26:848–50
2. Stanley MD, Davenport DL, Procter LD, Perry JE, Kearney PA, Bernard AC. An acute care surgery rotation contributes significant general surgical operative volume to residency training compared with other rotations. J Trauma. 2011;70:590–4
3. Compeau C, Tyrwhitt J, Shargall Y, Rotstein L. A retrospective review of general surgery training outcomes at the University of Toronto. Can J Surg. 2009;52:E131–6
4. Kohn GP, Nikfarjam M. The effect of surgical volume and the provision of residency and fellowship training on complications of major hepatic resection. J Gastrointest Surg. 2010;14:1981–9
5. Drake FT, Van Eaton EG, Huntington CR, Jurkovich GJ, Aarabi S, Gow KW. ACGME case logs: surgery resident experience in operative trauma for two decades. J Trauma Acute Care Surg. 2012;73:1500–6
6. Cronenwett JL, Liapis CD. Vascular surgery training and certification: an international perspective. J Vasc Surg. 2007;46:621–9
7. Konrad C, Schüpfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures? Anesth Analg. 1998;86:635–9
8. Starke RM, Asthagiri AR, Jane JA Sr, Jane JA Jr. Neurological surgery training abroad as a progression to the final year of training and transition to independent practice. J Grad Med Educ. 2014;6:715–20
9. Salazar D, Schiff A, Mitchell E, Hopkinson W. Variability in Accreditation Council for Graduate Medical Education Resident Case Log System practices among orthopaedic surgery residents. J Bone Joint Surg Am. 2014;96:e22
10. Wanderer JP, Charnin J, Driscoll WD, Bailin MT, Baker K. Decision support using anesthesia information management system records and accreditation council for graduate medical education case logs for resident operating room assignments. Anesth Analg. 2013;117:494–9
11. Simpao A, Heitz JW, McNulty SE, Chekemian B, Brenn BR, Epstein RH. The design and implementation of an automated system for logging clinical experiences using an anesthesia information management system. Anesth Analg. 2011;112:422–9
12. Veldenz HC, Dennis JW, Dovgan PS. Quality control of resident operative experience: compliance with RRC criteria. J Surg Res. 2001;98:81–4
13. Irby DM, Cooke M, O’Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med. 2010;85:220–7
14. Simien C, Holt KD, Richter TH, Whalen TV, Coburn M, Havlik RJ, Miller RS. Resident operative experience in general surgery, plastic surgery, and urology 5 years after implementation of the ACGME duty hour policy. Ann Surg. 2010;252:383–9
15. Daniels AH, Ames CP, Smith JS, Hart RA. Variability in spine surgery procedures performed during orthopaedic and neurological surgery residency training: an analysis of ACGME case log data. J Bone Joint Surg Am. 2014;96:e196
16. Kairys JC, McGuire K, Crawford AG, Yeo CJ. Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? J Am Coll Surg. 2008;206:804–11
17. Gow KW, Drake FT, Aarabi S, Waldhausen JH. The ACGME case log: general surgery resident experience in pediatric surgery. J Pediatr Surg. 2013;48:1643–9
18. McCoy AC, Gasevic E, Szlabick RE, Sahmoun AE, Sticca RP. Are open abdominal procedures a thing of the past? An analysis of graduating general surgery residents’ case logs from 2000 to 2011. J Surg Educ. 2013;70:683–9
19. Suwanabol PA, McDonald R, Foley E, Weber SM. Is surgical resident comfort level associated with experience? J Surg Res. 2009;156:240–4
20. Rosenberg TL, Franzese CB. Extremes in otolaryngology resident surgical case numbers. Otolaryngol Head Neck Surg. 2012;147:261–70
21. Gill DJ, Freeman WD, Thoresen P, Corboy JR. Residency training the neurology resident case log: a national survey of neurology residents. Neurology. 2007;68:E32–3
22. Bhattacharya P, Van Stavern R, Madhavan R. Automated data mining: an innovative and efficient web-based approach to maintaining resident case logs. J Grad Med Educ. 2010;2:566–70
© 2016 International Anesthesia Research Society
23. Langdorf MI, Montague BJ, Bearie B, Sobel CS. Quantification of procedures and resuscitations in an emergency medicine residency. J Emerg Med. 1998;16:121–7