Abstract
Background
In 2013, the Accreditation Council of Graduate Medical Education (ACGME) instituted a case minimum requirement for orthopaedic residents. It is unknown how pediatric orthopaedic case volume and variability have been affected by this change.
Methods
The ACGME orthopaedic surgery case log data from 2007 to 2020 were used to evaluate the number and type of pediatric orthopaedic procedures logged by graduating residents. The mean and median number of cases logged were compared for the years before (2007-2013) and after (2014-2020) the case minimum implementation using a Student t-test.
Results
In the period after case minimum implementation, there were significant decreases in both overall cases (2080.6-1639.2; P < .001) and pediatric cases (328.7-264.7; P < .001) logged by residents. However, pediatric case volumes in certain areas significantly increased. Pediatric humerus/elbow procedures went up by 19.7% (29.4-35.2; P < .001), driven by an increase in fracture and dislocation treatments (21.5-28.17, 31.0%; P < .001). Similarly, pediatric forearm/wrist procedures went up by 31.7% (33.7-44.5; P < .001), driven by an increase in manipulation (19.0-31.9, 67.8%; P < .001). All other anatomic areas besides the shoulder experienced significant decreases in case volume, including spine procedures, which experienced the greatest decrease: 52.1% (28.4-13.5; P < .001).
Conclusions
Paradoxically, since the implementation of case minimums in 2013, residents have logged fewer overall cases and pediatric orthopaedic cases. One may hypothesize that, when residents are required to submit a certain minimum number of cases, there is little incentive to submit additional cases.
Key Concepts
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1)
The ACGME instituted a case minimum requirement for Orthopaedic surgery residents starting in 2013.
-
2)
Since 2013, residents have logged fewer pediatric orthopaedic cases.
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3)
Since 2013, residents have logged fewer overall orthopaedic cases.
Level of Evidence
III, Cross-Sectional Study
Keywords: ACGME, Orthopaedic residency, Case minimum requirements, Pediatric orthopaedics
Introduction
The Accreditation Council of Graduate Medical Education (ACGME) is the governing body responsible for the accreditation of medical training programs in the United States, such as orthopaedic residency programs [1]. The ACGME uses a case log system whereby residents keep track of procedures performed during their training. In 2013, the ACGME implemented a set of guidelines, outlining a minimum number of 1000 overall cases to be performed by the end of orthopaedic residency. This curricular change included case minimums for specific procedure categories, such as 10 carpal tunnel releases, 15 ankle fracture fixations, 30 knee arthroscopies, and more (Table 1) [2]. Case minimums were established because operative experience is considered one of the most important factors when training residents [3]. However, it is unknown exactly how this new requirement has affected reported operative volumes and exposure. It has already been shown that significantly fewer knee and shoulder arthroscopies have been logged since this change [4].
Table 1.
Case minimums for orthopaedic residents to complete upon graduation, implemented by the ACGME in 2013.
| Category | Minimum |
|---|---|
| Knee arthroscopy | 30 |
| Shoulder arthroscopy | 20 |
| ACL reconstruction | 10 |
| THA | 30 |
| TKA | 30 |
| Hip fractures | 30 |
| Carpal tunnel release | 10 |
| Spine decompression/posterior spine fusion | 15 |
| Ankle fracture fixation | 15 |
| Closed reduction forearm/wrist | 20 |
| Ankle and hind and mid-foot arthrodesis | 5 |
| Supracondylar humerus percutaneous treatment | 5 |
| Operative treatment of femoral and tibial shaft fractures | 25 |
| All pediatric procedures | 200 |
| All oncology procedures | 10 |
ACGME, Accreditation Council of Graduate Medical Education; TKA, Total Knee Arthroplasty; THA, Total Hip Arthroplasty; ACL, Anterior Cruciate.
The largest current requirement during orthopaedic residency is 200 pediatric cases by the time of graduation. This can be achieved through both operative encounters (e.g., ACL reconstruction) and nonoperative encounters (e.g., closed reductions of the forearm and wrist). Residents at some institutions are required to share these cases with pediatric fellows, and although it is not universal among all programs, it is possible that priority is given to the latter group [5]. Pediatric orthopaedics is a rapidly growing area, with the number of fellowship programs increasing from 36 to 47 between 2010 and 2017 [6], [7]. To our knowledge, the impact of these changes on pediatric case volume during residency is unknown and is the subject of the current study.
Methods
Orthopaedic surgery case logs are self-reported by residents of ACGME-accredited residency programs. National data are published annually and reflect all the cases that were reported throughout residency for those graduating in that academic year [2].
Overall (both pediatric and nonpediatric) and pediatric case volumes were assessed for graduating residents between 2007 and 2020. The ACGME defined pediatric cases as those involving any patients younger than 17 years of age. These data were compared between 2 groups: those graduating from 2007 to 2013 (before implementation of case minimums) and those graduating from 2014 to 2020 (after implementation of case minimums). Pediatric cases were further analyzed according to anatomic areas (e.g., shoulder, spine) and procedure types (eg, arthroscopy, arthrodesis). The averages and standard deviations of these groups were compared using the Student t-test.
The ACGME also categorizes all graduating residents into 90th, 50th, and 10th percentiles according to the median number of completed pediatric cases. Temporal trends for these 3 groups were evaluated using linear regression analyses.
Results
The total reported number of overall and pediatric orthopaedic procedures for graduating residents between the years of 2007 and 2020 is presented (Fig. 1). After the implementation of case minimums in 2013, the overall (pediatric and nonpediatric) and pediatric case volumes both decreased by 21% (2080.6-1639.2; P < .001) and 19% (328.7-264.7; P < .001), respectively. However, pediatric case volumes in certain areas significantly increased. Pediatric humerus/elbow procedures went up by 19.7% (29.4-35.2; P < .001), driven by an increase in fracture and dislocation treatments in this area (21.5-28.17, 31.0%; P < .001). Similarly, pediatric forearm/wrist procedures went up by 31.7% (33.7-44.5; P < .001), driven by an increase in manipulation (19.0-31.9, 67.8%; P < .001). All other anatomic areas besides the shoulder experienced significant decreases in reported case volume, including spine procedures, which experienced the greatest decrease by 52.1% (28.4-13.5; P < .001) (Table 2). Temporal trends of all the pediatric procedures according to anatomic area and procedure type are presented in Supplemental Fig. 1A-I. The disparity in pediatric case volumes between the 90th, 50th, and 10th percentiles of orthopaedic residents significantly narrowed after the introduction of case minimums (Fig. 2).
Figure 1.
Mean number of overall orthopaedic cases and pediatric orthopaedic cases per graduating resident before (2007-2013) and after (2014-2020) Accreditation Council of Graduate Medical Education (ACGME) case minimums. Points in the gray shading indicate reported case volumes after ACGME case minimums were implemented.
Table 2.
Comparison of mean case volumes by graduating orthopaedic residents before (2007-2013) and after (2014-2020) implementation of ACGME case minimums.
| 2007-2013 | 2014-2020 | Percent change | P-value | |
|---|---|---|---|---|
| Overall orthopaedic case volume | 2080.6 ± 155.9 | 1639.2 ± 124.8 | −21.2% | <.001 |
| Pediatric orthopaedic case volume (all anatomic areas) | 328.7 ± 30.1 | 264.7 ± 19.0 | −19.4% | <.001 |
| Pediatric shoulder case volume | 5.9 ± 0.9 | 6.3 ± 0.5 | 6.6% | .363 |
| Pediatric humerus/Elbow case volume | 29.4 ± 2.5 | 35.2 ± 3.1 | 19.7% | .002 |
| Pediatric forearm/Wrist case volume | 33.7 ± 4.2 | 44.5 ± 5.8 | 31.7% | .002 |
| Pediatric hand/Finger case volume | 15.5 ± 1.0 | 14.1 ± 0.7 | −9.0% | .012 |
| Pediatric pelvis/Hip case volume | 26.4 ± 0.6 | 16.9 ± 0.7 | −35.7% | <.001 |
| Pediatric femur/Knee case volume | 47.7 ± 2.6 | 41.0 ± 4.3 | −13.8% | .006 |
| Pediatric leg/Ankle case volume | 40.3 ± 0.8 | 30.5 ± 2.9 | −24.4% | <.001 |
| Pediatric foot/Toe case volume | 22.0 ± 0.3 | 12.6 ± 0.7 | −42.5% | <.001 |
| Pediatric spine case volume | 28.4 ± 3.1 | 13.5 ± 0.8 | −52.1% | <.001 |
ACGME, Accreditation Council of Graduate Medical Education.
Bold P-values indicate statistical significance.
Figure 2.
Median number of pediatric orthopaedic cases per graduating resident in the 90th, 50th, and 10th percentiles before (2007-2013) and after (2014-2020) Accreditation Council of Graduate Medical Education (ACGME) case minimums. Points in the gray shading indicate reported case volumes after ACGME case minimums were implemented.
Discussion
The current study showed that the period after the implementation of case minimums had a significant decrease in both the number of overall (pediatric and nonpediatric) and pediatric procedures reported by graduating orthopaedic residents. Despite decreased total pediatric reported case volumes, there was an increase in case volumes for pediatric forearm/wrist procedures secondary to closed manipulations and an increase in humerus/elbow procedures secondary to treatments for fractures and dislocations. Additionally, the disparity in pediatric case volumes between the 90th, 50th, and 10th percentiles of orthopaedic residents significantly narrowed after the introduction of case minimums.
The significant decrease in pediatric case volume by 21.2% was similar to decreases in overall orthopaedic case volume (19.4%), suggesting that the curricular change affected orthopaedics as a whole during residency training. When evaluating the decreases in case volumes for shoulder and knee arthroscopies following case minimum implementation, Clark et al. [8] suggested the most likely reason was a lack of reporting by residents into the case log system—a trend demonstrated in several studies [9], [10], [11], [12]. When comparing case reporting with department records at a single institution, Okike et al. [9] found that orthopaedic residents failed to report 25% of their cases. Thus, it is possible that our observed drop in reported case volumes was secondary to residents logging incomplete case logs. In the present study, prior to case minimums, the 10th percentile of graduating residents, in terms of total pediatric procedures, completed 200 pediatric cases in only 1 of 7 years. After this curricular change, the 10th percentile achieved this mark in 6 out of 7 years. In contrast, the 90th and 50th percentiles, both of which groups far exceeded 200 pediatric cases prior to the start of case minimums, experienced drops in case volumes after these curricular changes—possibly because the residents did not log all their cases since minimums were already met. This may suggest that incomplete reporting practices by residents may be from a strategy to only report what is necessary to satisfy requirements.
One of the 2 pediatric procedure types to significantly increase was the closed manipulations of forearm/wrist fractures. After requiring graduating residents to complete at least 20 manipulations, reported cases increased from 19 to 31.9, more than 50% of what was required. Since forearm fractures are common in pediatrics, comprising nearly 40% of all fractures [13], [14], logging these reductions may pose as a convenient and fast way for residents to satisfy their 200 pediatric case minimum, even if they have already surpassed the 20 case minimum for forearm reductions. This concept is likely also true for pediatric humerus/elbow procedures, the other pediatric procedure type to significantly increase. Percutaneous pinning of supracondylar humerus fractures is listed as a separate entity on the ACGME guidelines (Table 1), but it is primarily a procedure done in pediatric patients. Additionally, with the recent growth in pediatric fellowship programs across the country, closed forearm reductions may serve as a more readily available opportunity for residents since other pediatric surgeries may go to fellows at their institutions.
Assessing resident case logs is important because they can often be used when making curricular decisions, such as when evaluating spine surgeons of neurosurgery and orthopaedic surgery training backgrounds [15]. Some of the described inaccuracies heighten the need for additional markers to evaluate resident education. Prior to case minimums, residents were assessed using a traditional time-based approach, such as evaluating the total number of operative hours. However, time spent learning a surgical skill does not necessarily define how well a person performs that skill [16], and with updated resident work-hour restrictions, there has been added reason to move away from this time-based approach. Competency-based education, on the other hand, focuses on advancing residents as they master a set of defined performance standards [17], [18], [19], [20]. Entrustable professional activities (EPA) have been proposed as a structured way to assess for completion of one of these competencies [21]. EPAs are core tasks that make up a management or assessment process [22]. An example of an EPA would be “managing a patient with shoulder pain,” which would involve diagnosing and supporting patients first with nonoperative care to technical skills during surgery and subsequent postoperative management. It has been suggested that the successful completion of an EPA can be used as a statement of awarded responsibility, signifying that a resident can perform a specific task unsupervised [23]. However, further progress will require stakeholders to agree on criterion-based objectives and assessment strategies, as well as consider the added burden such curricular changes may place on faculty. Nevertheless, the variable case reporting practices by residents found in this current study call into question whether an accurate and practical method of measuring case volume exists and may provide further reason to move toward competency-based education in United States Orthopaedic Residency Programs.
The current investigation has several limitations. First, changes in coding/unbundling practices over time may have contributed toward caseload variation. Second, although ACGME case minimums were implemented in 2013, residents record procedures gradually throughout their 5 years. Thus, residents who graduated in the years shortly after 2013 experienced reporting cases both with and without the influence of case minimums, which may call into question using 2007-2013 and 2014-2020 as our time intervals. However, similar time intervals have been used in previous studies [4], and the current authors believe that case reporting in the final years of residency makes up significant portions of graduating case volume. Another factor that cannot be accounted for is the variability with which specific residency programs emphasize case logging. It is possible that external motivations such as funding, program image, and the ability to expand are influencing how residents are encouraged and/or required to log cases. Lastly, the study period includes the year 2011, which is when the ACGME instituted a 16-hour limit on shifts for interns. This provides a possible limitation, as a duty-hour restriction could also reduce case volume; however, studies evaluating this demonstrated that, although intern case volume often decreased marginally, case volume for senior residents increased [24], [25], [26]. Thus, the current literature overall reports that the restrictions placed on surgical interns in 2011 did not significantly impact case volume over the duration of residency. In addition, for most orthopaedic residents, the volume of pediatric orthopaedic cases in predominantly obtained after their intern year. The duty-hour restriction is nonetheless a possible limitation of this study.
Conclusion
Paradoxically, since the implementation of case minimums in 2013, residents have reported fewer overall orthopaedic cases and pediatric orthopaedic cases. One may hypothesize that, when residents are only required to submit a certain number of cases, there is little incentive to put their limited time and energy into submitting additional cases.
Additional links
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•
ACGME Case Minimum Requirements https://www.acgme.org/globalassets/pfassets/programresources/260_ors_case_log_minimum_numbers.pdf
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Pediatric Resources for the OITE https://posna.org/blogs/resident-review/october-2021/key-peds-ortho-resources-for-the-oite
Funding
The authors declare that they did not receive funding.
Ethics approval and consent
This study contains no animal or human subjects and does not require informed consent.
Author contributions
Narendran Nakul: Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. Farivar Daniel: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. Illingworth Kenneth D: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing. Paiement Guy D: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing. Skaggs David L: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing.
Declaration of competing interests
Dr. Skaggs has received royalties and/or fees from Wolters Kluwer Health, Zimmer Biomet, Globus Medical, Medtronic, and Orthobullets and is a board member of the Pediatric Spine Foundation and CHLA Foundation, all outside the submitted work. Dr. Illingworth is a member of the JPOSNA® editorial board, has received consulting fees from OrthoPediatrics, and has participated on a DSMB or Advisory Board of Medtronic, all outside the submitted work. The following authors report no conflicts of interest related to the submitted work: Dr. Paiement, Mr. Farivar, and Mr. Narendran.
Footnotes
Supplementary material associated with this article can be found in the online version at doi:10.1016/j.jposna.2024.100009.
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References
- 1.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 Jt Surg Am. 2014;96(3) doi: 10.2106/JBJS.L.01689. [DOI] [PubMed] [Google Scholar]
- 2.Review Committee for Orthopaedic Surgery. Orthopaedic surgery minimum numbers. Published online 2014. 〈https://www.acgme.org/globalassets/pfassets/programresources/260_ors_case_log_minimum_numbers.pdf〉 (accessed June 26, 2022).
- 3.Kohring J.M., Bishop M.O., Presson A.P., et al. Operative experience during orthopaedic residency compared with early practice in the U.S. J Bone Jt Surg Am. 2018;100(7):605–616. doi: 10.2106/JBJS.17.01115. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Sabharwal S., Toci G.R., D’Sa A.A., Nayar S.K., LaPorte D.M. Decrease in resident arthroscopic case volume after 2013 implementation of minimum case requirements. Arthrosc Sports Med Rehabil. 2021;3(1):e205–e209. doi: 10.1016/j.asmr.2020.09.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Sadati L., Yazdani S., Heidarpoor P. Surgical residents’ challenges with the acquisition of surgical skills in operating rooms: a qualitative study. J Adv Med Educ Prof. 2021;9(1):34–43. doi: 10.30476/jamp.2020.87464.1308. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Pediatric Orthopaedics Fellowship. Published online 2017. 〈https://sfmatch.org/files/eb921e5f494a42f09a72e77d4c0e72ee〉 (accessed June 26, 2022).
- 7.Sawyer J.R., Jones K.C., Copley L.A., Chambers S., POSNA Practice Management Committee Pediatric orthopaedic workforce in 2014: current workforce and projections for the future. J Pedia Orthop. 2017;37(1):59–66. doi: 10.1097/BPO.0000000000000666. [DOI] [PubMed] [Google Scholar]
- 8.Clark S.C., Miskimin C., Mulcahey M.K. ACGME case volume minimums decrease the number of shoulder and knee arthroscopies performed by residents. Arthrosc Sports Med Rehabil. 2021;3(3):e689–e694. doi: 10.1016/j.asmr.2021.01.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Okike K., Berger P.Z., Schoonover C., Robert V.O. Do orthopaedic resident and fellow case logs accurately reflect surgical case volume? J Surg Educ. 2018;75(4):1052–1057. doi: 10.1016/j.jsurg.2017.12.002. [DOI] [PubMed] [Google Scholar]
- 10.Naik N.D., Abbott E.F., Aho J.M., et al. The ACGME case log system may not accurately represent operative experience among general surgery interns. J Surg Educ. 2017;74(6):e106–e110. doi: 10.1016/j.jsurg.2017.09.032. [DOI] [PubMed] [Google Scholar]
- 11.Nygaard R.M., Daly S.R., Van Camp J.M. General surgery resident case logs: do they accurately reflect resident experience? J Surg Educ. 2015;72(6):e178–e183. doi: 10.1016/j.jsurg.2015.04.022. [DOI] [PubMed] [Google Scholar]
- 12.Veldenz H.C., Dennis J.W., Dovgan P.S. Quality control of resident operative experience: compliance with RRC criteria. J Surg Res. 2001;98(2):81–84. doi: 10.1006/jsre.2001.6156. [DOI] [PubMed] [Google Scholar]
- 13.Cheng J.C., Ng B.K., Ying S.Y., Lam P.K. A 10-year study of the changes in the pattern and treatment of 6,493 fractures. J Pedia Orthop. 1999;19(3):344–350. [PubMed] [Google Scholar]
- 14.Jones K., Weiner D.S. The management of forearm fractures in children: a plea for conservatism. J Pedia Orthop. 1999;19(6):811–815. [PubMed] [Google Scholar]
- 15.Pham M.H., Jakoi A.M., Wali A.R., Lenke L.G. Trends in spine surgery training during neurological and orthopaedic surgery residency: a 10-year analysis of ACGME case log data. J Bone Jt Surg Am. 2019;101(22) doi: 10.2106/JBJS.19.00466. [DOI] [PubMed] [Google Scholar]
- 16.Safavi A., Lai S., Butterworth S., Hameed M., Schiller D., Skarsgard E. Does operative experience during residency correlate with reported competency of recent general surgery graduates? Can J Surg. 2012;55(4):S171–S177. doi: 10.1503/cjs.020811. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Nousiainen M.T., McQueen S.A., Hall J., et al. Resident education in orthopaedic trauma: the future role of competency-based medical education. Bone Jt J. 2016;98-B(10):1320–1325. doi: 10.1302/0301-620X.98B10.37031. [DOI] [PubMed] [Google Scholar]
- 18.Ferguson P.C., Kraemer W., Nousiainen M., et al. Three-year experience with an innovative, modular competency-based curriculum for orthopaedic training. J Bone Jt Surg Am. 2013;95(21) doi: 10.2106/JBJS.M.00314. [DOI] [PubMed] [Google Scholar]
- 19.Houston W.R. McCutchan Pub. Corp; San Pablo, CA: 1974. Exploring competency based education. [Google Scholar]
- 20.Tuxworth E. Routledge; San Pablo, CA: 1989. Competence based education and training: background and origins. [Google Scholar]
- 21.Mulder H., Ten Cate O., Daalder R., Berkvens J. Building a competency-based workplace curriculum around entrustable professional activities: the case of physician assistant training. Med Teach. 2010;32(10):e453–e459. doi: 10.3109/0142159X.2010.513719. [DOI] [PubMed] [Google Scholar]
- 22.Dwyer T., Wadey V., Archibald D., et al. Cognitive and psychomotor entrustable professional activities: can simulators help assess competency in trainees? Clin Orthop Relat Res. 2016;474(4):926–934. doi: 10.1007/s11999-015-4553-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ. 2013;5(1):157–158. doi: 10.4300/JGME-D-12-00380.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Awan M., Zagales I., McKenney M., Kinslow K., Elkbuli A. ACGME 2011 duty hours restrictions and their effects on surgical residency training and patients outcomes: a systematic review. J Surg Educ. 2021;78(6):e35–e46. doi: 10.1016/j.jsurg.2021.06.001. [DOI] [PubMed] [Google Scholar]
- 25.Scally C.P., Reames B.N., Teman N.R., Fritze D.M., Minter R.M., Gauger P.G. Preserving operative volume in the setting of the 2011 ACGME duty hour regulations. J Surg Educ. 2014;71(4):580–586. doi: 10.1016/j.jsurg.2014.01.004. [DOI] [PubMed] [Google Scholar]
- 26.Amabile A., Mori M., Brooks 2nd C., Weininger G., Shang M., Fereydooni S., et al. The impact of trainees’ working hour regulations on outcome in CABG and valve surgery in the State of New York. J Card Surg. 2021;36(12):4582–4590. doi: 10.1111/jocs.16058. [DOI] [PubMed] [Google Scholar]
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