Impact of a Pediatric Ambulatory Surgical Center on Surgery Resident Education

Abstract

OBJECTIVE:

Most operative education for surgery trainees occurs in primary academic hospitals. The impact of ambulatory surgery centers (ASCs) on resident operative experience with adult procedures is variable but has not been reported regarding pediatric cases. We hypothesized that the introduction of a pediatric ASC in our health system led to decreased opportunities for surgery residents to participate in ACGME-required cases.

DESIGN:

We performed a retrospective analysis of operative data from the electronic health record (EHR) and resident-reported case logs for procedures performed at an academic children’s hospital (CH) and its pediatric ASC from 2018 to 2023. Pediatric surgery first performed operations at the ASC in May 2020. Operative cases analyzed were those performed at both the ASC and the CH. The presence of trainees in overlapping case types was analyzed, and descriptive statistics were performed.

SETTING:

Vanderbilt University Medical Center, General Surgery training program and Vanderbilt Children’s Hospital, both quaternary care centers.

PARTICIPANTS:

General surgery residents rotating on the Pediatric Surgery service between 2018 and 2023.

RESULTS:

Overlapping cases included inguinal, umbilical, and epigastric herniorrhaphies, as well as subcutaneous lesion excisions. Of 17,012 cases performed by pediatric surgeons during the study period, 5,413 (31.8%) were overlapping cases, and 599 (3.5%) were performed at the ASC. Retrospective review of the EHR demonstrated resident presence in 82.9% of CH cases before the ASC and 81.8% afterwards. Resident presence in ASC cases was minimal (n = 9). Categorical General Surgery and Pediatric Surgery residents had no decrease in case volume after ASC initiation based on EHR data or case logs.

CONCLUSIONS:

The introduction of a pediatric ASC did not reduce resident operative experience but represents a missed educational opportunity in the ambulatory setting.

INTRODUCTION

Historically, most pediatric training of categorical General Surgery residents has taken place at academic children’s hospitals (CH).^1,2 In recent years, some centers, both adult and pediatric, have shifted operative volume to ambulatory surgery centers (ASCs).^3–6 The reasons for this shift are multifactorial. The option for ambulatory surgery can be beneficial to both hospitals and patients by offloading lower acuity volume, improving financial and operative efficiency, and improving accessibility to patients.^5–10 Several studies have investigated the impact of ASCs on resident education in adult surgical populations, but the effect on their training has been variable.^11–15 Furthermore, the impact of ASCs on categorical and pediatric surgery trainee education has not been reported.

The Accreditation Council for Graduate Medical Education (ACGME) sets a minimum required number of operative cases by category for each accredited type of surgical training program. Trainees must meet these minimum requirements to graduate residency and to be eligible for American Board of Surgery examinations. For categorical General Surgery residents, the minimum requirement for the pediatric category is 20 cases over 5 clinical years, and logged cases are also further delineated into major procedure types (e.g., “herniorrhaphy, inguinal/umbilical”, “repair pyloric stenosis”).^16,17 Pediatric Surgery residents (i.e., “fellows”) must meet a minimum requirement of 800 cases over 2 clinical years, which also includes minimum requirements for defined categories (e.g., “abdomen/GI”, “trauma/critical care”).^18,19 While operative case logs are certainly an incomplete measure of surgical trainee education, these numbers are a nationally consistent and objective metric of operative experience. As with studies on resident education at large, prior literature has not reported on the impact of ASCs on ACGME case logs.

In May of 2020, our institution began performing pediatric surgery cases at an off-site, designated pediatric ASC. Here, we report our novel findings based on operative data from the electronic health record (EHR) and ACGME case logs from our institution. The null hypothesis for this study was that there would be no difference in operative case experience for categorical General Surgery and Pediatric Surgery residents after the initiation of the ASC. The alternative hypothesis was that the ASC had a negative impact on operative case experience.

METHODS

Population and Ethical Approval

This study was performed at an academic, quaternary care CHs with a multistate catchment area and at a regional, pediatric ambulatory surgery center directly built for and managed through the primary CH. Institutional review board (IRB) approval was obtained for this study and for the use of all involved data (IRB #231957).

The CH and its affiliated adult academic medical center have both ACGME-accredited categorical General Surgery and Pediatric Surgery training programs. The categorical General Surgery residency is a 5-clinical year training program with an average of 8 residents per year, as well as over 20 preliminary postgraduate year (PGY) first- and second-year residents in a given academic year. All categorical General Surgery residents rotate on Pediatric Surgery for 8 weeks as interns (PGY-1) and 6-8 weeks as third years (PGY-3). Most preliminary Surgery interns spend 4 weeks on pediatric surgery during the first year (PGY-1). Additionally, General Surgery residents interested in Pediatric Surgery may spend additional time on the service during the fourth and/or fifth year (typically 1-2 residents per class; clinical PGY-4 and 5).

The Pediatric Surgery residency is an ACGME-accredited 2-year training program with 1 fellow per year (2 total at a time). Per ACGME guidelines, Pediatric Surgery fellows spend most of the 2 years on the pediatric surgery service, with occasional off-service rotations, such as Critical Care or Urology.

Electronic Health Record Data

EHR data on historical operative logs was queried for the 6-year period of January 1, 2018, to December 31, 2023. All cases with operative logs performed at either the main CH or the ASC by pediatric surgeons were extracted with variables, including case date, case location, primary surgeon, associated Current Procedural Technology (CPT) codes, and trainees logged as present during the case. In order for a trainee to be logged as present, including both residents and fellows, the surgical staff (i.e., circulator nurse) manually searches for the trainee in the Epic system and marks them as present. This documentation is a hospital policy for all personnel entering the operating room during the procedure.

Overlapping Subset Cases

The list of unique CPT codes associated with cases historically performed at both the CH and the ASC was identified and comprised the overlapping subset of cases. Trainee cases were assessed for residency level, taking both case date and training start date into consideration (e.g., cases performed as a first-year resident, as a third-year resident, etc.). Case numbers were then compared before or after May 1, 2020, which was the month in which cases were first performed at the ASC.

ACGME Data

ACGME case log data for the categorical Surgery residency program, available to the Surgery program director, were obtained. Three distinct report types provided by the ACGME online case log system were utilized: program case log reports, national case log reports, and current resident case logs. The program and national reports correspond to a given academic year (e.g., July 2022 – June 2023) and provide data on Surgery chief residents who graduated in that year. The reports contain statistics on case log counts for each of the primary case category, including pediatric surgery cases, as well as the major procedure types within each category (e.g., “herniorrhaphy, inguinal/umbilical”).

The current resident case data includes all cases logged by residents enrolled in the categorical Surgery residency program up to the time of data accession (in this case January 2024). Available variables reflect data manually submitted by Surgery residents and include procedure date, CPT code and procedure description, primary surgeon, procedure location, ACGME case category, current training year of the logging resident, and resident role in the case (first assistant, surgeon junior, surgeon chief, or teaching assistant). As with the EHR data, cases taking place between January 1, 2018, and December 31, 2023, were analyzed, and data were filtered only to include cases counting towards the pediatric surgery category. Cases were again analyzed by training year (i.e., first year, third year, etc.) and compared before and after the ASC initiation time point (May 1, 2020).

Statistics

All statistics pertaining to ACGME program and national case log reports were taken directly from available reports; no additional calculations were made on these data. Summary statistics were calculated for EHR and current resident ACGME case log data. After sampling, all data distributions were assumed to be nonparametric. A 2-tailed, unpaired t-test was used to compare data across the ASC initiation time point (May 1, 2020) where applicable, with p-values reported and where p < 0.05 was considered significant a priori.

RESULTS

Overlapping Subset Cases

From May 1, 2020, to December 31, 2023, 172 unique CPT codes were associated with cases performed at the ASC. As expected, these codes also associated with cases performed at the CH. These codes were used to define the overlapping subset of cases and are summarized in Table 1. Most codes related to basic herniorrhaphies, including inguinal, umbilical, and epigastric hernias, and procedures on skin and soft-tissue lesions (e.g., lesion excisions, incision and drainage procedures, and foreign body removals).

TABLE 1.

List of Overlapping Subset CPT Codes

CPT Codes (n = 172)	Description
10081, 11772	Pilonidal cyst operations
20520, 23330-03	Foreign body removal (soft tissue)
21502, 27372, 42725, 49013-14	Incision and drainage and wound explorations
11057, 11103, 11201, 11400-06, 11420-26, 11440-46, 11462-63, 11601-02, 11620-25, 11641, 17000-04, 17110, 17250, 17260-76, 17311-15, 19126, 21011-15, 21552-58, 21601-03, 21925, 21930-36, 22904, 23071-78, 24073-79, 25075-77, 25110, 26117, 26160, 27040, 27050, 27086-87, 27327-29, 27337-39, 27364-65, 27615-19, 1630-34, 28039-47, 28090-93, 38550, 38555, 42810, 42815, 43045, 96567-74	Skin and soft tissue lesion biopsies, excisions, and ablations
36589-90	Central venous catheter removal
43870	Gastrostomy closure
45990, 46604	Anorectal examination
49491-96, 49500-07, 49520-25, 49650-51	Inguinal hernia repair
49560-49566, 49568, 49591-95, 49613-18, 49591L, 49595L	Umbilical, incisional, and ventral hernia repair
54060, 54115, 54512, 54830, 55060, 55120, 55150	Circumcision, penile, and scrotal operations
77013, 77021	Other

CPT, current procedural terminology.

EHR Operative Data

EHR Operative Volumes

From January 1, 2018, to December 31, 2023, pediatric surgeons performed 17,012 operative cases at both institutional facilities. Before May 1, 2020, all cases were performed at the CH (n = 6,298; median 228.5 cases per month, IQR [216.0, 244.5]; Table 2). The first Pediatric Surgery case performed at the ASC was on May 5, 2020. From May 1, 2020, to December 31, 2023, 10,115 cases were performed at the CH (94.4%) and 599 cases were performed at the ASC (5.6%). A median of 230.5 cases per month were performed at the CH (IQR [218.5, 244.0]; p = 0.350), and 10.5 cases per month were performed at the ASC (IQR [7.5, 17.3]; Table 2). For overlapping subset cases, a median of 72.0 cases per month were performed at the CH before ASC initiation (IQR [66.5, 84.0]), and 62.0 cases per month were performed at the CH afterwards (IQR [54.0, 71.5]; p = 0.0034). At the ASC, all cases were part of the overlapping subset, so 10.5 cases per month were performed (IQR [7.5, 17.3]; Table 2).

TABLE 2.

Electronic Health Record Operative Logs

		All Cases			Overlapping Subset Cases
		Pre-ASC (n = 6298)	Post-ASC (n = 10714)	p-Value	Pre-ASC (n = 2048)	Post-ASC (n = 3365)	p-Value
Cases per month*
	Main hospital	228.5 [216.0, 244.5]	230.5 [218.5, 244.0]	0.350	72.0 [66.5, 84.0]	62.0 [54.0, 71.5]	0.003
	ASC	n/a	10.5 [7.5, 17.3]	n/a	n/a	10.5 [7.5, 17.3]	n/a
Trainee presence**
	Main hospital	5,222 (82.9%)	8,767 (81.8%)	n/a	1,679 (82.0%)	2,297 (83.0%)	n/a
	ASC	n/a	9 (1.5%)	n/a	n/a	9 (1.5%)	n/a
Trainee cases per month (by clinical year)*
Categorical general surgery residents	Year 1	21.0 [18.3, 33.5]	23.0 [13.5, 35.5]	0.743	11.0 [10.0, 16.8]	9.5 [6.0, 15.0]	0.174
	Year 2	2.0 [2.0, 2.0]	1.5 [1.0, 2.8]	0.689	n/a	1.0 [1.0, 3.0]	n/a
	Year 3	46.5 [40.3, 63.8]	51.0 [46.0, 60.5]	0.120	15.0 [8.0, 17.0]	13.0 [10.0, 16.5]	0.878
	Year 4	7.0 [5.0, 8.0]	5.0 [3.0, 8.0]	0.509	1.5 [1.0, 2.0]	1.0 [1.0, 2.0]	0.338
	Year 5	4.0 [2.0, 17.8]	5.0 [2.5, 8.0]	0.421	6.0 [1.0, 8.5]	1.5 [1.0, 4.0]	0.115
Pediatric surgery fellows	Year 1	42.0 [39.0, 49.0]	51.0 [43.0, 55.0]	0.017	7.0 [5.0, 9.0]	8.0 [5.0, 10.0]	0.165
	Year 2	41.0 [34.5, 47.5]	41.5 [31.0, 47.0]	0.829	6.5 [4.0, 9.5]	6.0 [4.0, 7.0]	0.334
Other residents/Fellows		41.0 [31.5, 55.0]	39.5 [32.8, 53.0]	0.298	24.0 [15.0, 31.0]	16.0 [12.5, 21.3]	0.010

Pre-ASC: January 2018 – April 2020. Post-ASC: May 2020 – December 2023.

^*median [IQR].

^**number (percent)

ASC, ambulatory surgery center.

To visualize case trends over time, case volumes were also analyzed in 6-month increments. Fig. 1 shows case volumes for both the CH and the ASC in 6-month increments over the entire study period, with trainee presence depicted as a percentage of each bar. It is evident that the number of cases performed at the ASC have increased over time. The number of cases performed at the CH appears to have decreased slightly in recent years, but the differences between monthly case volume before and after ASC initiation were not significant (Table 2). Furthermore, the total volume of cases (CH and ASC combined) has increased over the last 1.5 years. Trainee presence within cases was consistent over time. A notably lower trainee presence in the first study period emerged (2018 half 1). This observation is likely attributable to surgical staff unfamiliarity with the EHR (which was implemented in November 2017) in regard to the method and/or need to document trainees as present in cases.

FIGURE 1.

Operative case counts from the children’s hospital and the ASC during the study period, in 6-month intervals. Trainee presence at each site is indicated by a contrasting bar. Trainee presence in ASC cases was 0 or near-zero for all periods. ASC, ambulatory surgery center

EHR Resident Participation

Before ASC initiation, 82.9% of cases performed at the CH had at least 1 trainee (resident or fellow) logged as present in the case in the EHR. After ASC initiation, 81.8% of CH cases had a trainee logged as present (Table 2). Trainee participation in ASC cases was minimal (n= 9, 1.5%). First- and second-year Pediatric Surgery fellows and PGY-3 residents were recorded present in the highest number of cases both before and after ASC initiation, with median cases per month >40 before and after. PGY-1 residents were present for a median of >20 cases per month before and after ASC initiation (Table 2). First-year fellows had an increase from median 42.0 cases per month (IQR [39.0, 49.0]) to median 51.0 cases per month (IQR [43,0, 55.0]; p = 0.017), and no other comparisons showed significant difference (Table 2).

For overlapping subset cases, PGY-1 and 3 residents were recorded in the highest median number of cases each month, both before and after ASC initiation. No statistically significant differences were detected after ASC initiation for any categorical General Surgery residents or fellows (Table 2). In the “Other Residents/Fellows” category, which primarily consists of preliminary first year residents, a slight decrease was observed in median overlapping subset cases per month (24.0 [15.0, 31.0] to 16.0 [12.5, 21.3]; p = 0.010).

ACGME Case Logs

Chief Resident Case Reports

ACGME program and national case operative log reports were assessed for each of the 5 clinical training years falling completely within the study period. The number of chief Surgery residents graduated per year ranged from 6 to 9 (median and mode: 7; Table 3). No chief residents during this time period graduated with less than the required 20 pediatric surgery cases. For all pediatric surgery cases logged, the program average ranged from 39.0 to 50.3 (national percentile: 64-85; Table 3). For major pediatric surgery case types, the program average ranged from 23.4 to 28.9 cases (national percentile: 58-74). The only major pediatric surgery case type encompassed in the CH and ASC overlapping subset was “herniorrhaphy, inguinal/umbilical”. Graduated residents from our program documented an average number of pediatric hernia cases ranging from 14.1 to 18.1 (national percentile: 74-82).

TABLE 3.

ACGME Program and National Graduated Chief Resident Case Numbers

	Academic Period
	2018-2019	2019-2020	2020-2021	2021-2022	2022-2023
Chief residents in program	7	7	6	7	9
All pediatric cases
Program**	41.9 (69)	40.9 (65)	39.0 (64)	50.3 (85)	40.2 (70)
Pediatric cases – major case types only	41.9 (69)	40.9 (65)	39.0 (64)	50.3 (85)	40.2 (70)
National*	25.1	24.5	23.2	23.1	22.8
Program**	28.9 (74)	25.1 (66)	23.5 (58)	27.1 (74)	23.4 (66)
Pediatric hernia cases
National*	13.9	13.1	12.3	11.6	11.3
Program**	18.1 (80)	15.4 (74)	15.7 (77)	15.1 (82)	14.1 (79)

^*mean.

^**mean (national percentile).

Of note, given that the required Pediatric Surgery rotations at our residency program occur during the PGY-1 and 3 years and that most categorical Surgery residents take 2 years of professional development and research time after the PGY-3 year, few graduated chief Surgery residents included in these reports would have been potentially affected by the introduction of the ASC. Most residents who were PGY-1 or 3 residents after May 2020 are still active clinical residents in the program.

Current Resident Case Logs

At the time of reporting, ACGME case log data were available for 54 active clinical residents ranging from PGY-1 to 5. Data were not available for residents currently in professional development and research, i.e., not full-time clinical surgery residents. The number of cases that residents logged with procedure dates within the study period (2018-2023) was 28,045. Of these cases, 2,727 were logged as pediatric surgery cases (9.7%). PGY-1 residents logged a median of 16.5 pediatric surgery cases before ASC initiation (IQR [10.5, 29.5]) and a median of 23.0 cases after ASC initiation (IQR [15.0, 37.5], p = 0.422; Table 4). PGY-3 residents logged a median of 82.0 pediatric surgery cases before ASC initiation (IQR [76.8, 101.3]) and a median of 74.0 cases afterwards (IQR [65.0, 80.0], p = 0.089; Table 4). Few residents logged cases during the PGY-2, 4, or 5 years of training, consistent with program structure. During the PGY-4 year, 1 resident logged 49 cases, and 4 residents who logged cases during PGY-5 logged a median of 21.5 cases (IQR [1.0, 42.3]).

TABLE 4.

Current General Surgery Resident ACGME Case Logs

	All Cases			Overlapping Subset Cases
	Pre-ASC (n = 593)	Post-ASC (n = 1906)	p-Value	Pre-ASC (n = 80)	Post-ASC (n = 312)	p-Value
Cases per resident (by clinical year)*
Year 1	16.5 [10.5, 29.5] (n = 10)	23.0 [15.0, 37.5] (n = 26)	0.422	4.0 [1.0, 7.0] (n= 10)	6.0 >[4.0, 9.0] (n = 23)	0.177
Year 3	82.0 [76.8, 101.3] (n = 4)	74.0 [65.0, 80.0] (n = 15)	0.089	9.0 [7.5, 10.3] (n = 4)	10.0 [7.0, 11.0] (n = 15)	0.723

Pre-ASC: January 2018 – April 2020. Post-ASC: May 2020 – December 2023.

^*median [IQR]

ASC, ambulatory surgery center.

For overlapping subset cases, PGY-1 residents logged a median of 4.0 cases before the ASC (IQR [1.0, 7.0]) and 6.0 cases afterwards (IQR [4.0, 9.0], p = 0.177). PGY-3 residents logged a median of 9.0 overlapping subset cases before ASC initiation (IQR [7.5, 10.3]) and a median of 10.0 cases afterwards (IQR [7.0, 11.0], p = 0.723; Table 4).

DISCUSSION

These data demonstrate that the initiation of operative cases at a pediatric ASC did not deleteriously affect the operative experience of categorical General Surgery or Pediatric Surgery trainees. Thus, the stated null hypothesis was upheld. This finding was consistent in both data sets (EHR surgical logs and ACGME case logs), and in every level of trainee examined. The EHR data demonstrated no significant change in operative case volumes at the main CH after starting to perform cases at the ASC, and no decrease in trainee cases was observed in this data set. These findings also held true in the overlapping subset of cases, which is the subset in which trainees would be most likely to experience a negative change in operative experience.

In general, cases performed at ambulatory centers are routine surgeries on healthy patients with minimal anesthetic risk factors, as ambulatory centers are usually less fully equipped compared to hospitals. Analysis of the types of cases performed at our ambulatory center was consistent with this inherent bias, as the majority were basic herniorrhaphies and excisions of skin or subcutaneous lesions. There are also a variety of other factors affecting the choice to perform a case at an ASC or a children’s hospital, for example the geographic location of the ASC and call responsibilities of the pediatric surgeon. While this study focused on case types performed at both centers, another potentially meaningful sub-group are case types performed exclusively at the ASC after its initiation. These might represent a completely missed learning opportunity for trainees. In our data set, the only operation unique to the ASC was a genital lesion excision which was performed only once. We concluded that in our center the vast majority of case types performed at the ASC were still being performed at the CH as well.

In the ACGME case log data, our institution’s categorical Surgery residency program was consistently above the national average in pediatric cases logged by graduating chief residents, including pediatric hernia cases, for the 5 years of the study period. However, as discussed above, few residents have graduated at this time who may have been affected negatively by the ASC. When examining the case logs of current clinical residents, we did not detect any significant decrease in pediatric surgery cases logged. In fact, PGY-1 and 3 residents showed a slight increase in overlapping subset cases after the initiation of the ASC. These data are the first reported on the impact of a pediatric ASC on surgery trainee operative numbers and consistently demonstrated a negligible impact at our institution.

Despite this observation, pediatric surgery cases at the ASC clearly represent a missed educational opportunity. Of the 599 cases performed at the ASC between May 2020, and December 2023, only 9 cases were covered by 3 categorical General Surgery residents and none by Pediatric Surgery fellows. As discussed previously, most cases performed at the ASC were routine procedures such as hernia repairs, which are excellent learning cases for junior residents in particular. We would not expect, nor did we observe the pediatric surgery fellow experience to be detrimentally affected by a decrease in such cases, as their education is more focused on complex pediatric conditions.

Trainees can also benefit from participating in operative care in a highly efficient ambulatory setting, an experience which is largely lacking in academic training programs. However, integration of trainees into the ambulatory center experience will require changes on multiple levels.¹⁴ Upon interviewing residents who went to the ASC, 2 commented that ancillary staff informed them that they could not participate in those cases, which was unknown to their attending pediatric surgeon (“When I got there I was told by the operating room staff that I could not scrub or assist.”; “I… was promptly turned away at the door and told that residents were not allowed on the premises.”). It remains unclear whether these comments resulted from an actual policy or from unwillingness of staff to work with trainees. A third resident had an excellent experience and wished that they had had more opportunities to operate there. In addition to clarifying ASC policies, improving the resident experience will also necessitate the education of and setting expectations with ancillary operative staff. While certified First Assistants are provided at the ASC, they do not replace trainees’ educational level and sustained commitment to the patient care, EHR documentation, attention to patient well-being after hours (i.e., fielding overnight calls regarding pain or wound complications), and continuity in Surgery clinic, both pre- and postoperatively. Our position is that residents add superior value to the complete care of the pediatric surgical patient. Further, while we did not design this study to evaluate medical student exposure to ambulatory procedures, we note that those students who enter primary pediatric care will also miss out on this invaluable experience regarding the management of fundamental surgical problems in children, the physical exam and diagnostic process, and the indications to refer to a pediatric surgeon.

This study has several limitations that temper rigorous conclusions. First, these data reflect a single center’s operative experience and culture for resident inclusivity. Generalizability to other centers is unknown. Second, this comparative study was retrospective in design, which could introduce biases in aim development and data abstraction and interpretation. Third, both data sets used in this study are limited in detail. Based on the EHR operative log data, a significant percentage of cases (19.9%) did not show trainees participation. However, in the authors’ experience, nearly all cases performed at the CH have at least 1 trainee present. The most likely contributor to this discrepancy is the manual workflow required for a trainee to be marked as present for a case, lapses in which are likely leading to underestimation of trainee presence in cases. This introduces 2 potential biases in the data. The first is that operative staff at the ASC are likely less used to working with trainees and therefore more likely to forget to document them as present. We attempted to mitigate this bias by asking all current residents about their experience (if any) with the ASC to identify cases in which they participated, and those few encounters are documented above. Further, it is the impression of the faculty surgeon co-authors in this study that very few residents have participated in ASC procedures. The second potential bias is whether the rate of trainee presence in the data set increased over time with improved nursing staff familiarity with the EHR, which was introduced in November 2017. Indeed, in the first half of 2018, a lower rate of trainee presence was documented (Fig. 1). However, in later periods the trainee presence rate was relatively consistent, which decreases the likelihood that this bias contributed to the findings of this study. The authors acknowledge further that procedural coding for common anterior abdominal wall hernias changed in 2023 which could have confounded data for that year. However, we did include the updated CPT codes in our search algorithm for overlapping cases. Finally, this study did not evaluate operative metrics when residents participated or not, specifically, times and postoperative complications.

In the ACGME data, a previously discussed limitation is that the graduated chief resident reports (both program and national) do not yet adequately reflect the impact of the ASC on the residency program. Furthermore, resident case log data are manually logged and subject to data entry error and “fatigue” once minimum numbers are satisfied. Specifically, prior studies have suggested that case log data are most likely to suffer from underreporting, especially after trainees have met minimum requirements for relevant categories.²⁰ In this case, underreporting of pediatric surgery cases would only decrease the likelihood that resident operative experience was impacted negatively by the initiation of the ASC.

Here, we have described 1 center’s experience with the introduction of a pediatric ASC and the impact of case diversion on resident education. Data from both the EHR and categorical Surgery resident ACGME case logs demonstrated that initiation of an ASC did not deleteriously impact resident operative volume, even when residents covered only 1% of these ambulatory procedures. Despite this favorable outcome, cases performed at the ASC represent an untapped educational opportunity for Pediatric Surgery trainees and other learners at our institution. Future work will involve the integration of this opportunity into the resident educational experience and addressing attitudes towards surgical trainees. Options include development of an innovative Ambulatory Surgery rotation, perhaps best suited for a PGY-2, or expanding resident complement to permit approval for the Joint Surgery – Pediatric Surgery program.

ABBREVIATIONS

ACGME

Accreditation Council for Graduate Medical Education

ASC

ambulatory surgery center

CH

children’s hospital

CPT

Current Procedural Technology

EHR

electronic health record

IQR

interquartile range

IRB

institutional review board

PGY

postgraduate year