Strumwasser Aaron, Grabo Daniel, Inaba Kenji, Matsushima Kazuhide, Clark Damon, Benjamin Elizabeth, Lam Lydia, Demetriades Demetrios
From the Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, California.
J Trauma Acute Care Surg. 2017 Mar;82(3):470-480. doi: 10.1097/TA.0000000000001351.
Trauma training in general surgery residency is undergoing an evolution. Hour restrictions, the growth of subspecialty care, and the trend toward nonoperative management have altered resident exposure to operative trauma. We sought to identify trends in resident trauma training since the inception of the 80-hour workweek.
The Accreditation Council for General Medical Education Case Log Statistical Reports for Surgery was abstracted for general surgery resident trauma operative volume for the years 1999-2014. Resident trauma experience (operative caseload [OC]) was compared before inception of the 80-hour workweek (1999-2002) to after the 80-hour workweek began (2003 to current).
A trend toward decreased operative trauma for general surgery residents was observed (mean OC [before 80-hour workweek vs. 80-hour workweek], 39,252 ± 1,065.2 cases vs. 36,065 ± 1,291.8; p = 0.06). Trauma laparotomies increased (range, 5,446-9,364 cases) with corresponding decreases in vascular trauma (4,704 to 799 cases), neck explorations (1,876 to 1,370 cases), and thoracotomies (2,507 to 2,284 cases). By comparison, an increase in vascular/integrated cases was noted (mean OC [before 80-hour workweek vs. 80-hour workweek], 845 ± 44.2 vs. 1,465 ± 88.4 cases; p < 0.01). Resident deficiencies analyzed by time period (before 80-hour workweek vs. 80-hour workweek) demonstrated deficiencies in thoracic, abdominal, solid organ, and extremity-vascular trauma domains (p < 0.01 for each). Nontrauma cases were also on the decline, specifically in open thoracic, vascular, and solid organ surgery (p < 0.05 for each). Both 1- and 2-year fellowships offset deficiencies in trauma education.
Based on the data, an alarming number of graduates complete training with substantially less experience in defined trauma categories. Because of a decline in operative trauma volume, advanced fellowship training should be encouraged specifically for those interested in a career in trauma and acute care surgery.
普通外科住院医师培训中的创伤培训正在经历变革。工作时长限制、亚专科护理的发展以及非手术治疗的趋势改变了住院医师接触手术创伤的机会。我们试图确定自实行80小时工作周以来住院医师创伤培训的趋势。
提取了1999 - 2014年普通外科住院医师创伤手术量的美国医学教育认证委员会病例日志统计报告。将80小时工作周开始前（1999 - 2002年）与80小时工作周开始后（2003年至今）的住院医师创伤经验（手术病例数[OC]）进行比较。
观察到普通外科住院医师的手术创伤呈减少趋势（80小时工作周前与80小时工作周后的平均OC，分别为39252±1065.2例与36065±1291.8例；p = 0.06）。创伤剖腹手术增加（范围为5446 - 9364例），同时血管创伤（从4704例降至799例）、颈部探查（从1876例降至1370例）和开胸手术（从2507例降至2284例）相应减少。相比之下，血管/综合病例有所增加（80小时工作周前与80小时工作周后的平均OC，分别为845±44.2例与1465±88.4例；p < 0.01）。按时间段（80小时工作周前与80小时工作周后）分析的住院医师不足显示，在胸部、腹部、实体器官和肢体血管创伤领域存在不足（各领域p < 0.01）。非创伤病例也在减少，特别是在开胸、血管和实体器官手术方面（各方面p < 0.05）。1年和2年的专科培训弥补了创伤教育方面的不足。
根据数据，令人担忧的是，大量毕业生完成培训时在特定创伤类别方面的经验大幅减少。由于手术创伤量的下降，应特别鼓励对创伤和急性 care 手术感兴趣的人接受高级专科培训。
