Matthew D Nealeigh, DO, Walter B Kucera, MD, Matthew J Bradley, MD, E. Matthew Ritter, MD, W. Brian Sweeney, MD, Elliot M Jessie, MD, Carlos J Rodriguez, DO. Uniformed Services University / Walter Reed National Military Medical Center
Introduction: Recent decades brought revolutionary applications of technology to address surgical disease. Residency programs appropriately integrated advances into their curricula, however, newly-graduated military general surgeons often find themselves at sea, responsible for several thousand sailors. Austere shipboard surgical suites have limited laparoscopic and radiologic capabilities. We hypothesized that military surgery graduates have minimal operative experience for common afloat procedures, which have changed little in the post-laparoscopy era.
Methods: We examined Ship’s Surgeon logs across three decades to determine afloat case load before and after laparoscopic integration (1990’s vs. 2000’s), normalized to a 7-month deployment, and used t-tests to evaluate differences among five common afloat case categories (orthopedic/hand/other, urologic/gynecologic, appendectomy, hernia, anorectal). Resident logs from a single military treatment facility were examined (2012-2016), with emphasis on Chief Resident cases as a proxy for emerging competency.
Results: Logs from 13 platforms yielded 1629 logged procedures, comprising >200 months at sea from 1990-2017. The most common surgery performed was vasectomy, totaling 27% of major operations (290 of 1092). There was no difference in at-sea case mix over the time period in five categories: hand/orthopedic/other (2% vs. 6%, p=0.50), urologic/gynecologic (19% vs. 21%, p=0.91), appendectomy (15% vs. 20%, p=0.65), hernia (23% vs. 21%, p=0.82), and anorectal (33% vs. 15%, p=0.09). Interestingly, cases markedly declined in three categories: anorectal (11.6 vs. 3.3, p<0.01), hernia (30.6 vs. 3.3, p<0.01), and appendectomy (9.7 vs. 2.5, p<0.01).
| Cases per deployment | Cases per deployment | Resident cases | Resident cases |
|
|---|---|---|---|---|
| 1990's | 2000's | Chief Year (mean=181+/-8) |
Full Residency (mean=946+/-41) |
|
| Orthopedic/Hand | 2.1 | 0.8 | 0.04 | 0.4 |
| Urologic/Gynecologic | 40.1 | 6.7 | 0.4 | 4.0 |
| Open Appendectomy | 9.7 | 1.8 | 0.5 | 4.8 |
| Laparoscopic Appendectomy | 0.0 | 0.7 | 5.3 | 46.2 |
| Open Inguinal Hernia | 24.9 | 2.1 | 6.8 | 36.8 |
| Anorectal | 11.6 | 3.3 | 6.9 | 24.4 |
Chief resident operations were limited for ACGME case categories comparable to those expected afloat.
Conclusions: Current curricula and operative practices provide graduating residents with minimal exposure to specific cases, which may not translate to competency for the afloat surgeon’s austere operating environment. Leadership should examine curricula for reasonable training improvements while maintaining graduate medical education program integrity.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88460
Program Number: MSS19
Presentation Session: Full-Day Military Surgical Symposium – General Surgery Presentations
Presentation Type: MSSPodium