Abstract
Background:
Prior analyses of general surgery resident case logs have indicated a decline in the number of endocrine procedures performed during residency. This study aimed to identify factors contributing to the endocrine operative experience of general surgery residents and compare those who matched in endocrine surgery fellowship with those who did not.
Methods:
We analyzed the case log data of graduates from 18 general surgery residency programs in the US Resident Operative Experience Consortium over an 11-year period.
Results:
Of the 1,240 residents we included, 17 (1%) matched into endocrine surgery fellowships. Those who matched treated more total endocrine cases, including more thyroid, parathyroid, and adrenal cases, than those who did not (81 vs 37, respectively, P < .01). Program-level factors associated with increased endocrine volume included endocrine-specific rotations (+10, confidence interval 8–12, P < .01), endocrine-trained faculty (+8, confidence interval 7–10, P < .01), and program co-location with otolaryngology residency (+5, confidence interval 2 −8, P < .01) or endocrine surgery fellowship (+4, confidence interval 2–6, P < .01). Factors associated with decreased endocrine volume included bottom 50th percentile in National Institute of Health funding (−10, confidence interval −12 to −8, P < .01) and endocrine-focused otolaryngologists (−3, confidence interval −4 to −1, P < .01).
Conclusion:
Several characteristics are associated with a robust endocrine experience and pursuit of an endocrine surgery fellowship. Modifiable factors include optimizing the recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in general surgery residency.
Introduction
There has been a steady rise in the number of endocrine surgery cases in the United States over the past 2 decades, with well over 100,000 procedures projected to be performed annually.1,2 Coinciding with the increased number of endocrine surgery cases is an overall decrease in endocrine surgery experience among general surgery (GS) residents, which is particularly concerning because the majority of endocrine surgery in the United States is performed by general surgeons.1,3,4 Previous studies have reported that the projected volume of common endocrine surgery diseases will likely surpass the number of fellowship-trained endocrine surgeons.2,3 At the same time, the preparedness of GS residents to perform endocrine surgery upon completion of residency without additional training has been called into question. A survey of members of the American Association of Endocrine Surgeons (AAES) revealed a pervasive sentiment that graduating GS residents are not adequately prepared for independent surgical treatment of advanced endocrine disease.5
The trend toward specialization in GS residency has raised questions regarding the endocrine surgery experience of GS residents and how that experience affects their decision to pursue endocrine surgery as a career.6 To “prime the pump” with dedicated endocrine surgeons and understand how to provide better preparation and experience for future general surgeons, this study sought to identify individual- and program-specific factors associated with GS residents treating endocrine cases and matching them into an residents performing endocrine surgery fellowship. We hypothesized that residents who treat more endocrine cases more frequently match into fellowships and that residency programs in which dedicated endocrine surgeons serve as faculty and in which endocrine-specific rotations are built into the residency curriculum are associated with the treatment of more endocrine cases by GS residents. As procedure volume and residency characteristics are potentially modifiable factors, the findings of their analysis provide informative data for programs aiming to increase endocrine surgery fellowship matriculation.
Methods
The US Resident OPerative Experience (ROPE) Consortium was established as a collaboration between multiple institutions to evaluate the operative experience of GS residents. The case log data for all graduates from participating programs between 2010 and 2020 were collected along with both individual- and program-level data. The programs are all GS residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). The database contains case log data linked with individual resident demographic and educational data and program characteristics. Resident demographic and educational data include age, sex (self-reported), graduation year, race/ethnicity (Asian, Black, Hispanic, White, and Other), medical school location (ie, the United States or another country), completion of a dedicated research experience, and career choice categorized by fellowship or decision to directly enter practice. We collected these data and classified residents into low-, medium-, and high-volume tertiles based on total operative volume among all graduates in the cohort.
Program characteristics contained in the database include US region (Midwest, Northeast, Southeast, Southwest, and West), volume, size, and National Institutes of Health (NIH) funding status. We collected these data and categorized program size by the distribution of average yearly graduates as small (<5 per year), medium (5–6 per year), or large (≥7 per year). We categorized program case volume into low- (<1,094 cases), medium- (1095–1264 cases), and high- (>1265 cases) volume tertiles based on program average operative volume per graduate. We obtained NIH funding status via the Research Portfolio Online Reporting Tool and categorized programs into the top 50th percentile, bottom 50th percentile, or no percentile (non-funded).6,7
We also requested that programs submit endocrine-specific case log data and retrospectively surveyed program data to obtain additional endocrine-related program-level data. All total thyroid, parathyroid, and adrenal case data were submitted for each individual graduate, of which endocrine case data included pancreas endocrine case data. We categorized operative volume in terms of role as a surgeon junior, surgeon chief, or teaching assistant. We distributed a survey via Research Electronic Data Capture to collect information regarding program characteristics, including association with an AAES-accredited endocrine surgery fellowship; employment of fellowship-trained endocrine surgeons; employment of endocrine-focused general surgeons, defined as surgeons for whom >50% of practice is dedicated to endocrine surgery; co-location with an otolaryngology residency; employment of an endocrine-focused otolaryngologist, defined as an otolaryngologist for whom >50% of practice is dedicated to performing thyroid and parathyroid surgery; successful placement of GS graduates into AAES-accredited fellowships; and inclusion of an endocrine surgery-specific rotation in the GS residency curriculum.
Statistical Analysis
We analyzed categorical data using χ2 analysis or Fischer’s exact test as appropriate and reported the results as the total (n) and percentage (%). We analyzed continuous data using the Wilcoxon rank sum test and reported the results as the median and IQR. After performing multivariable linear regression to analyze total endocrine case volume, we selected covariates based on author consensus. The variables we included in the model were sex, race/ethnicity, NIH funding status, program size and operative volume, employment of fellowship-trained endocrine surgeons, employment of otolaryngologists performing endocrine surgery, association with an AAES-accredited fellowship, association with an otolaryngology residency, and inclusion of an endocrine surgery rotation in the curriculum. We established White male residents at small, low-volume, non–NIH-funded residency programs with no associated endocrine surgery program characteristics as the reference group. We performed statistical analysis using JMP Pro version 16.0 (SAS Institute, Cary, NC) and obtained approval for the study by the Institutional Review Board of the University of Cincinnati (2020–1197) and by each individual institution’s respective institutional review board, which granted a waiver of consent.
Results
Cohort characteristics
We included a total of 1,240 GS graduates who participated in residency programs between 2010 and 2020 from 18 ACGME-accredited GS residency programs in this study (Tables I and II). Most residents included in the dataset were male (64.9%) and White (68.9%), with a median age of 33 years. The median number of total endocrine procedures performed was 37 (IQR 21–56), and the median number of total thyroid, parathyroid, and adrenal procedures performed was 22 (IQR 13–35), 11 (IQR 6–19), and 2 (IQR 1–4), respectively. The year-to-year trends in total endocrine procedures performed by graduates and their operative subdomains (total thyroid, parathyroid, and adrenal cases) are shown in Supplementary Figure S1. Whereas all (100%) programs were associated with an otolaryngology department, 4 (22.2%) were associated with an AAES-accredited endocrine surgery fellowship, and 15 (83.3%) with an otolaryngology residency. Thirteen (72.2%) institutions employed fellowship-trained endocrine surgeons, 6 of whom (33.3%) were endocrine-focused general surgeons, and 6 (33.3%) were endocrine-focused otolaryngologists. Eleven (61.1%) programs successfully placed a resident in an endocrine surgery fellowship, and 11 (61.1%) had an endocrine surgery-specific rotation as a part of their GS residency curriculum.
Table I.
US Resident Operative Experience. Consortium resident demographics
| Resident demographics | All residents, no. (%) N = 1240 |
AAES Fellowship-bound residents, no. (%) (N = 17) |
Other residents, no. (%) (N = 1223) |
P value |
|---|---|---|---|---|
| Age (y) | 33 (31–34) | 32 (32–34) | 33 (31–34) | .54 |
| Sex | .07 | |||
| Female | 435 (35.1%) | 10 (58.8%) | 425 (34.8%) | |
| Male | 805 (64.9%) | 7 (41.2%) | 798 (65.3%) | |
| Race/ethnicity | .50 | |||
| Asian | 206 (16.6%) | 5 (29.4%) | 201 (16.4%) | |
| Black | 59 (4.8%) | 0 (0.0%) | 59 (4.8%) | |
| Hispanic | 66 (5.3%) | 1 (5.9%) | 65 (5.3%) | |
| White | 854 (68.9%) | 11 (64.7%) | 843 (68.9%) | |
| Other | 55 (4.4%) | 0 (0.0%) | 55 (4.5%) | |
| US medical school graduate | .24 | |||
| Yes | 1106 (89.2%) | 17 (100.0%) | 1089 (89.0%) | |
| No | 134 (10.8%) | 0 (0.0%) | 134(11.0%) | |
| Dedicated research time | .47 | |||
| Yes | 546 (44.0%) | 9 (52.9%) | 537 (43.9%) | |
| No | 694 (56.0%) | 8 (47.1%) | 686 (56.1%) | |
| Graduate operative volume | .66 | |||
| Low | 410 (33.1%) | 7 (41.2%) | 403 (33.0%) | |
| Medium | 421 (34.0%) | 6 (35.3) | 415 (33.9%) | |
| High | 409 (33.0%) | 4 (23.5%) | 405 (33.1%) |
Table II.
US Resident Operative Experience. Consortium program characteristics
| Program characteristics | All residents, no. (%) (N = 1240) |
AAES Fellowship-bound residents, no. (%) (N = 17) |
Other residents, no. (%) (N = 1223) |
P value |
|---|---|---|---|---|
| Program type | 1.00 | |||
| Community | 98 (7.9%) | 1 (5.9%) | 97 (7.9%) | |
| University | 1142 (92.1%) | 16 (94.1%) | 1126 (92.1%) | |
| Program size | .75 | |||
| Small | 119 (9.6%) | 1 (5.9%) | 118 (9.7%) | |
| Medium | 564 (45.5%) | 7 (41.2%) | 557 (45.5%) | |
| Large | 557 (44.9%) | 9 (52.9%) | 548 (44.8%) | |
| Program region | .81 | |||
| Midwest | 340 (27.4%) | 6 (35.3%) | 334 (27.3%) | |
| Northeast | 174 (14%) | 3 (17.6%) | 171 (14.0%) | |
| Southeast | 470 (37.9%) | 6 (35.3%) | 464 (37.9%) | |
| Southwest | 200 (16.1%) | 2 (11.8%) | 198 (16.2%) | |
| West | 56 (4.5%) | 0 (0.0%) | 56 (4.6%) | |
| Program NIH funding | .15 | |||
| Top 50 | 656 (52.9%) | 13 (76.5%) | 643 (52.6%) | |
| Bottom 50 | 277 (22.3%) | 2 (11.8%) | 275 (22.5%) | |
| None | 307 (24.8%) | 2 (11.8%) | 305 (24.9%) | |
| Program operative volume* | .80 | |||
| Low | 369 (29.8%) | 6 (35.3%) | 363 (29.7%) | |
| Medium | 455 (36.7%) | 5 (29.4%) | 450 (36.8%) | |
| High | 416 (33.5%) | 6 (35.3%) | 410 (33.5%) | |
| Employed faculty | ||||
| Endocrine surgeons† | .78 | |||
| Yes | 936 (75.5%) | 14 (82.4%) | 922 (75.4%) | |
| No | 304 (24.5%) | 3 (17.6%) | 301 (24.6%) | |
| Endocrine-focused general surgeons | 1.0 | |||
| Yes | 368 (31.7%) | 5 (33.3%) | 363 (31.7%) | |
| No | 792 (68.3%) | 10 (66.%) | 782 (68.3%) | |
| Otolaryngologists‡ | .20 | |||
| Yes | 431 (34.8%) | 3 (17.6%) | 428 (35.0%) | |
| No | 809 (65.2%) | 14 (82.4%) | 795 (65.0% | |
| AAES-accredited fellowship | .10 | |||
| Yes | 351 (28.3%) | 8 (47.1%) | 343 (28.0%) | |
| No | 889 (71.7%) | 9 (52.9%) | 880 (72.0% | |
| Otolaryngology residency | .71 | |||
| Yes | 1097 (88.5%) | 16 (94.1%) | 1081 (88.4%) | |
| No | 143 (11.5%) | 1 (5.9%) | 142 (11.6%) | |
| Successful AAES match§ | .03 | |||
| Yes | 880 (71.0%) | 16 (94.1%) | 864 (70.6%) | |
| No | 360 (29.0%) | 1 (5.9%) | 359 (29.4%) | |
| Endocrine surgery rotation | .02 | |||
| Yes | 836 (67.4%) | 16 (94.1%) | 820 (67.0%) | |
| No | 404 (32.6%) | 1 (5.88%) | 403 (33.0%) |
AAES, American Association of Endocrine Surgeons; NIH, National Institutes of Health.
Low = < 1,094 cases, medium = 1095–1264 cases, high = >1265 cases.
AAES-fellowship trained endocrine surgeons.
More than 50% of their practice constituting endocrine surgery.
A graduate of the program successfully matched into an AAES-accredited endocrine surgery fellowship.
Comparison of graduates pursuing endocrine fellowships
Of the 1,240 GS graduates we examined, 17 (1.4%) successfully matched into an endocrine surgery fellowship, and 1,223 (98.6%) either went directly into practice or pursued a different fellowship (Tables I and II). Of the entire cohort, 238 (19.2%) went directly into practice and 1,002 (80.8%) matched into a fellowship. No significant demographic differences existed between residents who matched into an endocrine surgery fellowship and those who did not. Residents who matched into an endocrine surgery fellowship graduated more often from a program that previously placed trainees into an endocrine surgery fellowship (94.1% vs 70.6%, P = .03) or had a dedicated endocrine rotation in their curriculum (94.1% vs 67.0%, P = .02).
Residents who successfully matched into an endocrine surgery fellowship graduated after having treated more than twice the number of total endocrine cases than those who did not (81 vs 37, respectively, P < .01). Within the subdomains of endocrine surgery, GS residents pursuing a fellowship in endocrine surgery treated more thyroid (52 vs 21, P < .01), parathyroid (25 vs 11, P < .01), and adrenal (4 vs 2, P < .01) cases compared to GS residents who matched into a different fellowship or went directly into practice (Table III). These differences in case numbers were consistent for each surgeon role (surgeon junior, surgeon chief, and teaching assistant) within each of the endocrine subdomains of thyroid, parathyroid, and adrenal surgery (all P < .05), with the only exception being the treatment of adrenal cases as surgeon junior (1 vs 1, P = .17).
Table III.
Case volume of residents pursuing an American Association of Endocrine Surgeons-accredited fellowship
| Resident cases performed | AAES fellowship-bound Residents Median (IQR) |
Other residents Median (IQR) |
P value |
|---|---|---|---|
| Total endocrine cases | |||
| Surgeon chief | 22 (15–43) | 11 (4–20) | < .01 |
| Surgeon junior | 49 (21–58) | 21 (11–40) | < .01 |
| Teaching assistant | 1 (0–4) | 0 (0–0) | < .01 |
| Total | 81 (59–99) | 37 (21–55) | < .01 |
| Thyroid cases | |||
| Surgeon chief | 13 (8–23) | 6 (2–11) | < .01 |
| Surgeon junior | 28 (11–39) | 13 (6–25) | < .01 |
| Teaching assistant rowhead | 0 (0–2) | 0 (0–0) | < .01 |
| Total rowhead | 52 (25–64) | 21 (13–34) | < .01 |
| Parathyroid cases | |||
| Surgeon chief | 7 (2–15) | 2 (1–6) | < .01 |
| Surgeon junior | 14 (9–19) | 7 (3–13) | < .01 |
| Teaching assistant | 0 (0–2) | 0 (0–0) | .03 |
| Total | 25 (15–33) | 11 (6–18) | < .01 |
| Adrenal cases | |||
| Surgeon chief | 3 (2–4) | 1 (0–2) | < .01 |
| Surgeon junior | 1 (0–2) | 1 (0–1) | .17 |
| Teaching assistant | 0 (0–0) | 0 (0–0) | < .01 |
| Total | 4 (3–6) | 2 (1–4) | < .01 |
AAES, American Association of Endocrine Surgeons.
Endocrine operative experience multivariable analysis
Table IV shows the results of multivariable linear regression analysis of the impact of various individual- and program-level factors on endocrine operative experience. Individual characteristics associated with an increased number of total endocrine procedures performed included Asian race/ethnicity (+4 cases, 95% CI 1–6, P < .01), whereas those associated with a decreased number of total endocrine cases included Black race/ethnicity (–5 cases, 95% CI −9 to −1, P = .02). Program factors associated with treating an increased number of total endocrine cases included having an endocrine surgery-specific rotation in the curriculum (+10 cases, 95% CI 8–12, P < .01), employment of an AAES-trained endocrine surgeon (+8 cases, 95% CI 7–10, P < .01), and association with an otolaryngology residency (+5 cases, 95% CI 2–8, P < .01). Programs with high overall operative volume (+5 cases, 95% CI 3–6, P < .01), an AAES-accredited fellowship (+4 cases, 95% CI 2–6, P < .01), and of medium size (+3 cases, 95% CI 1–6, P < .01) were also associated with treating an increased total endocrine cases. Program factors associated with treating a decreased number of total endocrine cases included ranking in the bottom 50th percentile in NIH funding (−10 cases, 95% CI −12 to −8, P < .01), large size (−9 cases, 95% CI −12 to −7, P < .01), and employment of otolaryngologists performing endocrine surgery (−3 cases, 95% CI −4 to −1, P < .01).
Table IV.
Interaction between individual and program factors with endocrine surgery operative volume
| Individual/Program factors | Estimate* | 95% CI | P value | ||
|---|---|---|---|---|---|
| Intercept | 30 | 27 | to | 33 | Reference |
| Sex female | 0 | −1 | to | 1 | .80 |
| Race/ethnicity Black | −5 | −9 | to | −1 | .02† |
| Race/ethnicity Asian | 4 | 1 | to | 6 | < .01† |
| Race/ethnicity Hispanic | 3 | −1 | to | 7 | .15 |
| Race/ethnicity other | −3 | −8 | to | 1 | .16 |
| Program size large | −9 | −12 | to | −7 | < .01† |
| Program size medium | 3 | 1 | to | 6 | < .01† |
| NIH funding top 50th percentile | 1 | −2 | to | 3 | .46 |
| NIH funding bottom 50th percentile | −10 | −12 | to | −8 | < .01† |
| Program operative volume high | 5 | 3 | to | 6 | < .01† |
| Program operative volume medium | 1 | −1 | to | 2 | .52 |
| Faculty, endocrine surgeon‡ | 8 | 7 | to | 10 | < .01† |
| Faculty, dedicated endocrine otolaryngologist§ | −3 | −4 | to | −1 | < .01† |
| Other AAES-accredited fellowship | 4 | 2 | to | 6 | < .01† |
| Other associated otolaryngology residency | 5 | 2 | to | 8 | < .01† |
| Other endocrine surgery rotation | 10 | 8 | to | 12 | < .01† |
AAES, American Association of Endocrine Surgeons; NIH, National Institutes of Health.
Results of multivariable linear regression analysis are displayed. The reference group was set as White male residents at small, low-volume, non-NIH funded residency programs with no associated endocrine surgery program characteristics, which represents the intercept in the model. Estimates for total endocrine surgery case volumes along with lower and upper limits corresponding to the bounds of 95% CIs are shown with associated P values.
Text here.
An AAES-fellowship trained endocrine surgeon.
An otolaryngologist for whom thyroid and parathyroid surgery constitutes >50% of practice.
Discussion
Endocrine surgery is a core aspect of general surgery, one that is experiencing an increasing disease burden at the same time as a shortage of experienced providers who can perform endocrine surgeries and manage the complex array of endocrine patients.2,3 In this multi-institutional study, we analyzed individual- and program-specific factors that impacted the endocrine surgery experience of GS residents and evaluated factors associated with matching into endocrine surgery. We found that various factors were associated with the number of endocrine cases that GS residents treat, including race/ethnicity, program size, type of faculty who perform endocrine surgery, and association of residency with an endocrine surgery fellowship or endocrine surgery-specific rotation. We found that residents who matched into an endocrine surgery fellowship (1) performed more cases than their peers in all sub-domains of endocrine surgery, (2) were more likely to graduate from a program that previously matched graduates into an endocrine surgery fellowship, and (3) trained at a program that includes an endocrine surgery-specific rotation in the curriculum. Our findings expand upon those of earlier studies into the specialization of GS residents and help identify ways to both improve the resident experience in endocrine surgery and encourage more residents to pursue careers in endocrine surgery.
Program-specific factors that influenced the number of total endocrine procedures performed and/or whether GS residents matched into endocrine surgery as a career included previous successful placement of a graduate into an AAES-sponsored fellowship, co-location with an AAES-sponsored fellowship, and having an endocrine surgery-specific rotation. These findings suggest that a pipeline is needed to encourage graduates to pursue endocrine surgery. An alumnus of the program matching implies that the program has sufficient exposure to endocrine surgery faculty and networking opportunities to allow residents to form connections and receive guidance before applying for a fellowship. The existence of an endocrine surgery-specific rotation suggests that case and clinic volume is substantial enough to support at least one resident on service full-time.
A national survey of endocrine surgery fellows and recent graduates found that 73% of fellows had formal endocrine surgery faculty at their institution during residency, which supports sufficient magnitude of faculty mentorship.8 The majority (94%) of residents who matched into an endocrine surgery fellowship graduated from a program with an endocrine surgery-specific rotation. In contrast, over half of the residents who matched into an endocrine surgery fellowship did not come from a program with an associated fellowship. Taken together, these results suggest that the immersive experience of an endocrine surgery rotation, where one is interacting with faculty, caring for patients, and performing operations, is a critical factor for a successful match.
It is important to note that co-location with an endocrine surgery fellowship does not negatively impact endocrine surgery case numbers for GS residents. In fact, according to our data, it actually increases the number of endocrine procedures performed by residents, which is likely due to the provision of access to established faculty and centers that can support fellows. In an analysis of data from 9 endocrine surgery fellowships, Hanks et al found no significant decrease in GS resident case volume.9 A follow-up 5-year longitudinal study assessing GS resident case volume immediately after the establishment of an endocrine fellowship also demonstrated no effect.10 Complex general surgical oncology fellowships require fellows to complete a minimum of 15 endocrine cases. Although we did not evaluate their presence in this study, previous research indicates that the provision of surgical oncology fellowships may have some effect on the number of endocrine procedures performed by GS residents.11
Both GS residents and otolaryngology residents train to perform neck endocrine procedures. This study found that the type of faculty employed and the presence of an otolaryngology residency affected the total endocrine case volume of GS residents. Somewhat predictably, we found that the employment of an endocrine surgeon as faculty increased the number of cases performed by GS residents. Although employing an otolaryngologist who performed endocrine surgery decreased the number of cases performed by GS residents, co-location with an otolaryngology residency increased the number of cases. These findings highlight the evolving dynamic between endocrine surgeons and otolaryngologists working together to share the space of thyroid and parathyroid surgical disease.
The increased case volume associated with co-location with an otolaryngology residency may reflect the size of the academic center. A larger patient population and referral base point toward an academic medical center able to support both an otolaryngology residency and a GS residency, specifically supporting the ability to increase the number of endocrine cases performed by both types of residents. This premise is supported by the finding that residents from programs in the bottom 50th percentile of NIH funding treat significantly fewer endocrine cases. Further work is needed to understand how to optimize training for both GS and otolaryngology residents by providing productive collaborations between the 2 specialties.
In addition to the program-specific factors that affect the endocrine surgery experience of GS residents, it is important to note the individual factors that impact the number of endocrine procedures performed by GS residents. In our cohort, 1.4% of residents matched into endocrine surgery, which is comparable to the 1.9% of residents who entered an endocrine surgery fellowship nationally within this same time frame(Emily Williams, Project Coordinator for the American Association of Endocrine Surgeons, BA, 1/17/2023 online e-mail).12 Similarly, our finding that our cohort of endocrine surgery fellowship–bound residents was 58.8% female and 64.7% White is comparable to those of prior reports.8,13 Black race/ethnicity was associated with decreased endocrine case volume, whereas Asian race/ethnicity was associated with increased endocrine case volume, consistent with a previous study by the ROPE Consortium that found that Black residents graduated after having treated fewer total cases than White residents.14
A national survey of current and recent endocrine surgery fellows in 2014 found that only 13% were Black.8 In contrast, Asian race/ethnicity was associated with increased endocrine case volume, and Asian GS residents comprised 29.4% of residents who pursued endocrine surgery within the ROPE Consortium, which is comparable to other studies assessing the representation of Asian surgeons among recent and current endocrine surgery fellows.13 One explanation for this discrepancy in endocrine case volume may relate to a stronger presence of Asian faculty and mentorship in the field of endocrine surgery relative to other non-White endocrine surgeons. Clearly, disparities exist in this field, particularly in regard to Black residents, and understanding and mitigating this disparity must be undertaken to improve the endocrine surgery experience for these residents.
Although highlighting ways to recruit GS residents to the field of endocrine surgery is important, this study also focuses on ways to improve the endocrine experience for all GS residents, including those who choose to forgo fellowship. This is especially important given that a large proportion of endocrine cases are historically and currently performed by non-fellowship–trained general surgeons.4,15 As GS residents who wish to pursue a rural or broad-based practice do not treat as many endocrine cases as those who pursue fellowship, they may need to seek out additional opportunities if they plan to perform endocrine operations. These opportunities may include participating in external rotations during residency to supplement their endocrine caseload or finding an experienced mentor to advise them as they transition to independent practice.
Pursuing a focused practice designation (FPD) for general surgeons may be another route to becoming competent in endocrine surgery. Participation in FPD programs, which were approved in 2017, aims at standardizing and acknowledging the additional expertise that physicians obtain by concentrating their clinical practice on specific areas within a specialty or subspecialty.16 The AAES is currently developing an FPD in Adult Complex Thyroid/ Parathyroid Surgery,17 a certification that provides an additional avenue for general surgeons to develop and maintain their skills in thyroid and parathyroid surgery as a subset of a broad-based practice.
Study limitations
This study has several limitations which should be acknowledged. First, although this was a multi-institutional study with a large cohort of residents, it did not capture all GS residency programs and may be subject to selection bias. Second, due to individual variation in how residents choose to log cases and define their role within operations, the data are subject to inaccuracies inherently introduced by case-logging practices. Third, the program-associated variables included in our multivariable analysis may contain some degree of dependency, resulting in a degree of collinearity that should be acknowledged when interpreting the results. Notably, we compared groups in terms of the number of graduates who matched into endocrine surgery fellowships and those who did not without having information regarding the ultimate scope of the practice. Despite expectations, fellowship-trained endocrine surgeons may not go on to dedicated endocrine surgery positions, whereas general surgeons may go on to build practices dedicated to endocrine surgery. Finally, we did not evaluate case log information for otolaryngology residency programs, which may have provided an additional perspective on the working relationship between otolaryngologists and endocrine surgeons.
In conclusion, this multicenter study identified both individual- and program-level characteristics associated with a more robust endocrine surgery experience. Modifiable program factors subject to optimization include the pipeline recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in the GS residency curriculum. Providing faculty mentorships or external rotations created in conjunction with the AAES may help recruit residents to the field while also enhancing the GS endocrine surgery experience as a whole. Racial disparities exist that may affect the endocrine surgery experience of GS residents and should be further explored and mitigated. Further research is needed to determine whether implementing these recommendations improves the GS endocrine experience and increases the presence of a diverse endocrine surgeon workforce in the long term.
Supplementary Material
Funding/Support
This research did not receive any specific funding from any agencies in the public, commercial, or not-for-profit areas.
Footnotes
Supplementary materials
Supplementary material associated with this article can be found, in the online version, at https://doi.org/10.1016/j.surg.2023.05.048
Conflict of interest/Disclosure
The authors have no conflicts of interests or disclosures to report.
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