RESEARCH RECHERCHE

Does operative experience during residency

correlate with reported competency of recent
general surgery graduates?
Arash Safavi, MD*
Sarah Lai, MD
Sonia Butterworth, MD*
Morad Hameed, MD, MPH*
Dan Schiller, MD
Erik Skarsgard, MD*
From the Departments of Surgery,
*University of British Columbia,
Vancouver BC, and University of
Alberta, Edmonton, Alta.
Accepted for publication
Dec. 9, 2011
Correspondence to:
E. Skarsgard
K0-123 ABC, 4480 Oak St.
Vancouver BC V6H 3V4
eskarsgard@cw.bc.ca
DOI: 10.1503/cjs.020811

Background: Identification of attributes of residency training that predict competency would improve surgical education. We hypothesized that case experience during
residency would correlate with self-reported competency of recent graduates.
Methods: Aggregate case log data of residents enrolled in 2 general surgery programs were collected over a 12-month period and stratified into Surgical Council on
Resident Education (SCORE) categories. We surveyed recent (< 5 yr) residency graduates on procedural competency. Resident case volumes were correlated with survey
responses by SCORE category.
Results: In all, 75 residents performed 11 715 operations, which were distributed by
SCORE category as follows: essential-common (EC) 9935 (84.8%), essential-uncommon
(EU) 889 (7.6%) and complex 891 (7.6%). Alimentary tract procedures were the most
commonly performed EC (2386, 24%) and EU (504, 56.7%) procedures. The least
common EC procedure was plastic surgery (4, 0.04%), and the least common EU
procedure was abdomenspleen (1, 0.1%). The questionnaire response rate was 45%.
For EC procedures, self-reported competency was highest in skin and soft tissue,
thoracic and head and neck (each 100%) and lowest in vascularvenous (54%),
whereas for EU procedures it was highest in abdomengeneral (100%) and lowest in
vasculararterial (62%). The correlation between case volume and self-reported competency was poor (R = 0.2 for EC procedures).
Conclusion: Self-reported competency correlates poorly with operative case experience during residency. Other curriculum factors, including specific rotations and timing,
balance between inpatient and outpatient surgical experience and competition for
cases, may contribute to procedural competency acquisition during residency.
Contexte : Une reconnaissance des attributs de la formation des rsidents qui permettent de prdire les comptences amliorerait lenseignement dans cette spcialit. Nous
avons formul lhypothse selon laquelle l'exprience avec des cas au cours de la rsidence serait en corrlation avec les comptences autodclares par les rcents diplms.
Mthodes : Nous avons recueilli les donnes agrges des registres des cas des rsidents inscrits 2 programmes de chirurgie gnrale sur une priode de 12 mois et
nous les avons stratifies selon les catgories du Surgical Council on Resident Education (SCORE). Nous avons interrog les rsidents finissants (< 5 ans) au sujet de leurs
comptences procdurales et avons tabli une corrlation entre leur volume de cas et
leurs rponses au sondage par catgorie SCORE.
Rsultats : En tout, 75 rsidents ont effectu 11 715 chirurgies, rparties comme suit
selon les catgories SCORE : interventions essentielles-courantes (EC), 9 935
(84,8 %), essentielles-peu courantes (EPC), 889 (7,6 %) et complexes, 891 (7,6 %). Les
interventions touchant les voies digestives ont t les plus frquentes EC (2 386, 24 %)
et EPC (504, 56,7 %). Les interventions EC les plus rares ont t des chirurgies plastiques (4, 0,04 %) et lintervention EPC la moins frquente a t une chirurgie de labdomen impliquant la rate (1, 0,1 %). Le taux de rponse au questionnaire a t de
45 %. Dans le cas des interventions EC, les comptences autodclares ont t les plus
leves pour les chirurgies de la peau et des tissus mous, thoraciques et de la tte et du
cou (chacune, 100 %) et les plus faibles, pour les interventions vasculaires veineuses
(54 %), tandis que dans le cas des interventions EPC, les comptences autodclares
ont t les plus leves pour les chirurgies abdominales gnrales (100 %) et les plus
faibles, pour les chirurgies vasculaires artrielles (62 %). La corrlation entre le volume
de cas et les comptences autodclares a t faible (R = 0,2 pour les interventions EC).
Conclusion : Les comptences autodclares sont en pitre corrlation avec lexprience des cas chirurgicaux durant la rsidence. Dautres facteurs du programme dtudes,

2012 Canadian Medical Association

Can J Surg, Vol. 55, (4 Suppl. 2) August 2012

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RECHERCHE
y compris certains stages prcis et le moment de leur tenue, un quilibre entre les interventions chez des patients hospitaliss et non hospitaliss et la concurrence pour l'attribution des cas peuvent contribuer lacquisition des comptences procdurales durant
la rsidence.

urgical residency must prepare future general surgeons for a variety of professional experiences,
ranging from subspecialty practice in urban centres
to general surgical practice in rural communities in which
the full complement of surgical specialty coverage may be
lacking. Canadian data on the distribution of general surgeons by practice type include the 2011 Canadian Association of General Surgeons (CAGS) survey in which 19% of
335 respondents identified their practices as community
in type.1 The 2009 CAGS survey identified 14% of respondents as practising in a community with a population of
50 000 or fewer, whereas 47% of respondents worked in
centres with a population of 500 000 or more.2
Depending on the specific needs of a surgical practice
and the operative expertise acquired during residency,
newly trained surgeons may feel variably prepared for their
professional roles. Kaminsky and colleagues3 reported that
most Canadian residents in their final year of training
expressed confidence with basic general surgical procedures, including laparoscopic cholecystectomy, appendectomy, mesh hernia repair, simple mastectomy and hemorrhoidectomy, yet expressed a lack of confidence in their
ability to perform procedures that are often required in
rural jurisdictions, including gynecological, genitourinary
and orthopedic surgery. The same appears to be true for
advanced laparoscopic procedures, with less than 25% of
Canadian-trained residents reporting feeling comfortable
performing laparoscopic splenectomy, Heller myotomy,
fundoplication and adrenalectomy.4 Hence, Canadian general surgical training programs face a challenge in producing graduates whose acquired skills during residency
result in self-perceived competence during early professional practice. Despite formalization of surgical curricula
and the establishment of CanMEDS training competencies,5 it seems likely that gaps exists between competencies
achieved during residency and competencies required
across the spectrum of Canadian general surgical practice.
In recognition of the diversity of expertise required by
Canadian general surgeons and of the critical need for general surgeons in community-based practice,6 the present
study sought to compare the educational and technical
skills acquired during residency with the skill set requirements perceived by recent general surgical graduates of
2 western Canadian general surgical training programs.

METHODS
We conducted a prospective, institutional research board
approved study involving general surgery residents at the
University of Alberta (UofA) and University of British
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J can chir, Vol. 55, (4 Suppl. 2) aot 2012

Columbia (UBC), and surgeon graduates of both programs

who were within their first 5 years of practice. Both residency programs lead to eligibility for certification by the
Royal College of Physicians and Surgeons of Canada and
the American Board of Surgery. Both universities have other
postgraduate surgical training programs that have some
overlap with general surgery: UofA has fellowship programs
in hepatobiliary and transplant, minimally invasive/bariatric,
thoracic and acute care surgery, whereas UBC offers fellowship training in minimally invasive, pediatric, thoracic
and vascular surgery.
General surgery resident case experience
Case volumes for selected surgical and endoscopic procedures performed by general surgery residents at the 2 programs who commenced their training on or before July 1,
2009, were included. Residents whose current year of training was interrupted by planned (e.g., research) or unplanned absences were excluded. Both programs use T-RES
(Resilience Software Inc.) case-counting software, and only
those cases in which the resident logged his or her role as
primary surgeon or teaching assistant were counted.
Aggregate case numbers were combined between the
2 programs. To allow for differences in program length
(5 yr at UofA v. 6 at UBC), aggregate operative case experience was subcategorized according to postgraduate year
(PGY) as either junior (PGY 12) or senior (PGY 36).
Operative case categories
The aggregate surgical case experiences of residents from
the UofA and UBC programs were then categorized
according to the Surgical Council on Resident Education
(SCORE) case classification system, which was developed
by the U.S. Association of Program Directors in Surgery.7
This operative case classification tool stratifies resident
operative experiences into 3 categories, with the following
definitions.
1. Essential-common (EC) comprises frequently performed operations in general surgery; specific procedure competency is required by the end of training (and
should be attainable primarily by case volume).
2. Essential-uncommon (EU) includes rare, often urgent,
operations seen in general surgery practice and not typically performed in high volume by trainees; specific
procedure competency is required by the end of training (but cannot be attained by case volume alone).
3. Complex describes procedures not consistently performed by general surgeons in training and not typically

RESEARCH

performed in general surgery practice. Generic experience

in complex procedures in residency is required, but competence in individual complex procedures is not required.
Some residency programs may provide sufficient experience for competence in some specific procedures.
The UBC program directors reviewed the SCORE case
categorization in detail and amended it slightly to more
accurately reflect Canadian general surgery residency
training expectations.
Self-reported competencies of recent general
surgery program graduates
Surgeons who had graduated from the UofA or UBC general surgery residency programs within the last 5 years
were contacted by letter and/or email and invited to participate in this study. Those who consented were sent a
link to a questionnaire. After 1 week, everyone was sent a
second message, which served as a thank you for those
who had already responded and as a friendly reminder for
those who had not. Three weeks later, a follow-up email
with a questionnaire link was sent to nonresponders only.
Two weeks after this, nonresponders offices were contacted by phone to verify postal/email addresses before
sending out a final invitation to participate.
The questionnaire was designed to collect information on
practice demographics; subspecialty training (if any); general
surgery call (among subspecialists); and the benefit of additional, specific residency training. In addition, using the
modified SCORE-categorized operative case lists, each surgeon was asked to self-report his or her perceived procedural
competency using a 3-point scoring system, with 3 indicating
fully competent, 2 somewhat competent and 1 not competent). An aggregate competency score for each procedure was
determined from the actual score divided by the maximum
possible score and expressed as a percentage. For example, if
5 surgeons reported full competence (5 3 = 15) and 5 surgeons reported partial competence (5 2 = 10), the aggregate
competency score would be 25 30 100 = 83%.

(n = 9) and PGY-6 (n = 8). Cases for which the resident was

not the primary surgeon or teaching assistant were
excluded, leaving a total of 11 715 (74.3%) cases for analysis. The case numbers per modified SCORE category were
9935 EC, 889 EU and 891 complex. Alimentary tract procedures were most commonly performed in the EC (2386,
24%) and EU (504, 56.7%) categories. The least commonly
performed EC procedures were plastic surgery (4, 0.04%),
abdomenspleen (40, 0.4%) and thoracic (49, 0.5%),
whereas the least commonly performed EU procedures
were abdomenspleen (1, 0.1%), pancreas and endocrine
(each 12, 1.3%), and vasculararterial (15, 1.7%).
General surgical graduate competencies
In all, 9 of 25 (36%) and 10 of 17 (58%) identified surgical
graduates completed the UofA and UBC surveys, respectively, for an overall response rate of 19 of 42 (45%). Of the
19 respondents, 8 had completed 1 or 2 years of additional
subspecialty training after their general surgery residency.
Among subspecialty-trained surgeons, 6 of 8 took general
surgery call. The practice demographics and details of
additional training of respondents are shown in Table 1.
Self-reported competency for EC cases was highest for
skin and soft tissue, thoracic and head and neck (each
100%) and lowest for vascularvenous (54%), plastic
surgery (55%) and endoscopy (84%). For EU cases, selfreported competency was highest for abdomengeneral
(100%), head and neck (96%), and skin and soft tissue and
abdomenhernia (each 93%) and lowest for vascular
arterial (62%), endocrine (63%) and alimentary tract
(80%). Of the 19 respondents, 9 (47%) indicated that they
could have benefited from additional training during residency, with rotations in plastic surgery and surgical oncology being the areas most frequently cited (Table 2).
Table 1. Attributes of recent graduates of general surgery
residency programs
Attribute

No. (%)

Sex

Statistical analysis

Male

15 (78.9)

Female

We calculated the procedure-specific correlation between

the aggregate case volume of general surgery residents
and the aggregate competency score of recent general
surgery graduates for EC and EU categories using the
Pearson product moment correlation coefficient.

4 (21.1)

Population of the community served

50 000100 000
More than 100 000
Hospital type
24/7 coverage for all surgical subspecialties
24/7 coverage for all surgical subspecialties not available
Subspecialty training

RESULTS
Residents
A total of 15 764 logged cases were abstracted from 75 residents with a PGY distribution as follows: PGY-1 (n = 15),
PGY-2 (n = 16), PGY-3 (n = 13), PGY-4 (n = 14), PGY-5

5 (21.1)
14 (78.9)

Pediatric surgery

8 (42.1)
11 (57.9)
8 (42.1)
1 (12.5)

Thoracic surgery

1 (12.5)

Hepatobilliary

1 (12.5)

Colorectal

1 (12.5)

Minimally invasive surgery

1 (12.5)

Trauma, intensive care unit

3 (37.5)

Subspecialty trained but cover general surgery calls

6 (75.0)

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Residents at UofA complete 1 month of plastic surgery

rotation in their junior years, whereas UBC residents do
not have this rotation at all. There is no specific surgical
oncology rotation at UofA, whereas UBC offers a month
of surgical oncology rotation as a junior and 3 months as a
senior. About 75% of junior and 50% of senior residents
are assigned to surgical oncology at UBC. The type and
duration of surgical rotations in each program are summarized in Table 3.
Pearson correlation analyses (Figs. 13) established a
weak association between resident aggregate case volumes
and surgical graduates perceived competencies for EC
cases only (R = 0.2). There was essentially no correlation
between case volume and reported competency for EU
cases. Despite the weakness of overall correlation for EC
cases, there was an association trend between decreased
competency reported by general surgeons and low case
numbers performed by residents. For instance, lowest perceived competency among graduates (vascularvenous and
plastic surgery) corresponded with very low resident case
volumes for these procedural categories (Fig. 1).

DISCUSSION
Training general surgeons to be competent assumes that
operative skills and knowledge acquired by the end of residency will match what is required in surgical practice. For
surgeons in rural communities, the scope of surgical skills
required often goes beyond that which is taught in a traditional general surgery residency program. A report from a
recent graduate general surgeon in British Columbia
expressed concern about residency preparation for community practice in multiple specialty areas, including pediatric surgery, endoscopy and hand surgery.8 A survey comparing urban and rural surgeons in the United States
found that a perceived need for additional training was

greater in 7 of 8 specialty areas (gynecology, cesarean sections, urology, thoracic surgery, endoscopy, orthopedics,
plastic surgery and hand surgery) among surgeons in rural
practice. 9 This opinion is supported by practice data,
which demonstrate that rural surgeons spend 27% of their
operative time performing endoscopic, gynecologic,
orthopedic, urologic and otolaryngology procedures. This
is in contrast to the 5% of operative time that urban surgeons devote to operations that most training programs
would consider to be outside of the classic realm of general surgery.10
An awareness of the unique surgical skill set required of
Table 3. Type and duration of rotations by training program
Duration of residency, mo.
UBC
Rotation

UofA

Junior (1, 2) Senior (36) Junior (1, 2) Senior (35)

General surgery

716 *

12

Vascular surgery

20
2

Endocrine

GS

GS

GS

GS

Colorectal

GS

GS

GS

GS

Thoracic surgery

Community surgery

312

Acute surgery

GS

GS

Surgical oncology

GS

GS

Trauma

GS

GS

Endoscopy

Pediatric surgery

Plastic surgery

HPBtransplant

GS

GS = no dedicated rotation experience attained during general surgery rotation;

HPB = hepatopancreatobiliary; UBC = University of British Columbia; UofA = University
of Alberta.
*Minimum of 7 months. Includes a 3-month rotation on service, which provides a
combined experience of colorectal with thyroid and parathyroid surgery, all residents
rotate on service.
Minimum of 3 months.
Includes thyroid and parathyroid experience, only a subgroup (75% as junior, 50% as
senior) is assigned to this rotation.

Table 2. Aggregate self-reported competencies and areas of need for additional training among recent graduates of general
surgery residency programs
Essential-common

% competency

Abdomengeneral

96

Essential-uncommon
Abdomengeneral

% competency
100

Abdomenhernia

93

Abdomenhernia

Abdomenliver and biliary

98

Abdomenspleen

91

Alimentary tract

96

Pediatric surgery

Additional training needed

No.

Surgical oncology

93

Minimally invasive surgery

Abdomenliver and biliary

81

Plastic surgery

Pancreas

82

Thoracic surgery

Abdomenspleen

88

Head and neck surgery

91

Alimentary tract

80

Orthopedic

Plastic surgery

55

Skin and soft tissue

93

Vascular surgery

Endoscopy

84

Trauma

87

Urology

Breast

99

Vasculararterial disease

62

Pediatric surgery

91

Thoracic surgery

81

Neurosurgery

100

Pediatric surgery

83

Trauma

Obstetrics/gynecology

Endocrine
Skin and soft tissue
Surgical critical care

96

Genitourinary

88

Vascularvenous

54

Head and neck

96

Endocrine

63

Thoracic surgery

100

Head and neck

100

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RESEARCH

1370
1016

100

surgery rotations since 1991, and the UofA general surgery

program has a 3-block rural rotation in PGY-4). Nonetheless, based on recent Canadian reports citing deficiencies in
600

100
90

96
408

500

80
70

50

300

40
200

30
31
59

100
4
8

0
1

Endocrine

12
5

Head and neck

27
5

Genitourinary

Trauma

Vasculararterial disease

Abdomenspleen

15
5

Pediatric surgery

4
11

0
1

Pancreas

Abdomenhernia

Abdomengeneral

1
11

Alimentary tract

12
27

5
16

20
26

Thoracic surgery

32
47

Skin and soft tissue

20
10

Case volume

400
60

Abdomenliver and biliary

Perceived competency

surgeons who are going to practice in rural jurisdictions

has resulted in the development of broadly based training
programs in the United States. One in particular, the Mary
Imogene Bassett Hospital in central New York State, has
for 50 years employed a rural hospitalbased curriculum
that has resulted in its graduates performing more cases in
the areas of genitourinary, plastics, hand, gynecology, nervous system and orthopedics procedures than the national
averages of all U.S. programs.9,11 Another study estimated
that about 10% of U.S. programs offer training that is
somewhat adapted to the needs of rural surgeons based on
any 1 the following 3 attributes: rural location of training
program, rural-focused curriculum and self-identified
interest in rural training. However, these attributes alone
do not necessarily identify programs that are more likely to
place graduates into rural practice settings.12
The situation in Canada is less well studied, but almost
certainly comparable. From a perspective of geography
(land area) and population density, the need for broadly
trained surgeons may be proportionately greater in Canada
than in the United States. Unlike the situation in the
United States, Canadian general surgery training programs
have remained rooted in urban centres by the nature of
their affiliation with large universities. However, many have
modified the traditional urban teaching hospitalbased curriculum to include rotations at more rural locations (for
example, the UBC general surgery program has had rural

Type of procedure
Aggregate junior resident cases
Aggregate senior resident cases
Total average score/total possible score 100

Fig. 2. Residents aggregate essential-uncommon case volumes

and surgical graduates perceived competencies.

2500

90

Type of procedure
Aggregate senior resident cases
Aggregate junior resident cases
Total average score/total possible score 100

Fig. 1. Residents aggregate essential-common case volumes

and surgical graduates perceived competencies.

9
6

29
8

15
6

1
2

Cardiac procedures

Endoscopy

Head and neck

Nervous system

0
0

Gynecology

1
6

0
0

Vascularvenous

Alimentary tract

Pancreas

1
0

Trauma

4
0

Vasculararterial disease

20

21
2

28
10

1
33

17
14

Skin and soft tissue

23
28

Head and neck

5
44

Thoracic surgery

32
22

Vascularvenous

Skin and soft tissue

Surgical critical care

1
3

Breast

Alimentary tract

Pediatric surgery

Abdomenspleen

Abdomenhernia

Abdomenliver and biliary

Abdomengeneral

24
132

Endocrine

9
80

27
13

36
8

40

Vascularaccess

216 156
93 149

10

60

500

Abdomengeneral

235
117

Endoscopy

20

80

Genitourinary

30

73
15

Plastic surgery

1000

Thoracic surgery

40

100

Abdomenliver and biliary

50

60
49

86
18

Transplantation

798
375

81
39

120

Case volume

1500

863
484

Case volume

60

33
101

140

975
652

Plastic surgery

Perceived competency

70

160

2000

Pediatric surgery

264
1729

80

Type of procedure
Aggregate senior resident cases
Aggregate junior resident cases

Fig. 3. Resident aggregate complex case volumes by residency

level. Junior = postgraduate year (PGY) 13; senior = PGY 46.
Can J Surg, Vol. 55, (4 Suppl. 2) August 2012

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RECHERCHE

preparedness for rural surgical practice,6,8 we conducted the

present study to explore more thoroughly the association
between resident case logs and the perception of competence of recently graduated general surgeons.
Our survey identified specific clinical areas where surgeons perceived insufficient competence. For EC procedures, these areas included plastic surgery, vascular venous
and, to a lesser extent, endoscopy, whereas for EU procedures, areas included vasculararterial and endocrine. Essential common procedures, by SCORE definition, are procedures for which competency is primarily attainable by
sufficient case volume, yet we found that the overall correlation between resident case volumes and surgeons selfreported competency for both EC and EU cases was poor,
although resident case volumes were extremely low (5 cases
or fewer) for some procedures associated with insufficient
competence (e.g., plastic surgery).
If resident surgical case volumes are a poor proxy for a
surgical graduates competence, then there are likely to be
other curriculum factors that contribute to the development of competence. An obvious factor is whether the curriculum includes a formal rotation in a specific discipline.
For plastic surgery, for example, it is likely that the lack of a
formal rotation at UBC and a short rotation at UofA
results both in a low number of performed procedures
(technical competence) and a lack of clinical expertise,
which together likely contribute to self-perceived competence. However, simply offering an inpatient rotation in a
focused discipline does not guarantee that residents will
receive the educational exposure necessary for competence
acquisition. Whereas most general surgery training programs require a rotation in vascular surgery, which exposes
residents to inpatient vascular surgery, there is likely to be
limited exposure to outpatient varicose vein surgery.
Another curriculum determinant of reduced competence
may be a lack of clarity or logistical barriers to achieving
subspecialty-specific training objectives within a general
surgery program. A recent study by Sidhu and colleagues13
suggested that varicose vein surgery, leg amputation and
femoral embolectomy are procedures for which competency should be achieved by Canadian general surgery residents during the course of training, yet the extent to which
that is achievable is unknown.
Another curriculum variable that likely contributes to
the development of competence is the timing of a rotation
within the 5- or 6-year residency. This may be relevant to
the acquisition of competence in pediatric surgery, which
tends to be a junior resident rotation, as data from the
2 programs surveyed indicate. High competence in EC
procedures in this category (91%) despite limited operative
experience could have been attained by performing similar
procedures (e.g., appendectomy, hernia repairs) on adults.
On the other hand, most EU procedures were exclusive to
pediatric surgery (e.g., excision of thyroglossal duct cyst),
and were performed in limited numbers. As a result, our
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J can chir, Vol. 55, (4 Suppl. 2) aot 2012

data showed a pattern of insufficient competence (83%) in

general surgery graduates. The same appears to be true for
endoscopy (84%), in which junior residents performed
most reported cases and senior residents performed fewer
but more advanced endoscopies (e.g., endoscopic retrograde cholangiopancreatography).
Competence in endocrine and vascular arterial surgery
may have been diminished owing to competition for operative case experience between general surgery residents
and subspecialty fellows. Such a phenomenon in endocrine
surgery among general surgical graduates has been well
documented in the United States and has been variably
attributed to the evolution of minimally invasive adrenal
surgery (for which general surgery residents are likely to
compete with minimally invasive surgery [MIS] fellows)
and to competition with otolaryngology training programs
for thyroid and parathyroid surgery.14 The centralization of
subspecialty general surgery (e.g., colorectal, endocrine,
surgical oncology, advanced laparoscopy) into centres of
excellence may decrease resident experience owing to
competition with an affiliated fellowship program. One fellowship that has become especially popular is MIS. Kothari
and colleagues15 demonstrated that despite the coexistence
of an MIS fellowship, general surgery residents did not
experience a reduction in the total number of basic and
nonbariatric advanced laparoscopic cases, nor did they perform fewer operations during the chief year.
Although hepatopancreaticobiliary (HPB) surgery has
traditionally been in the domain of general surgeons, our
data and that of others suggest that despite exposure to
advanced HPB surgery and liver transplantation, the experience obtained is unlikely to be sufficient to produce
competency in liver and pancreas resections,16 which themselves are procedures that should not be performed outside
of specialty centres. Therefore, reduced competence in
HPB surgery is less relevant than, for example, competence
in varicose vein surgery for recent graduates practising outside of a specialty centre.
Our study has a number of important findings, including
the identification of several practice areas (particularly plastic, vascular, and endocrine surgery and surgical oncology),
in which recent program graduates self-report insufficient
competence. Our data suggest that case volume alone does
not determine competence, but that there are other curricu lar factors involved, such as the specific rotations
offered; the balance between inpatient and outpatient experience; the timing of rotations in junior versus senior
years; and the effects of other programmatic influences,
including subspecialty centralization and the competition
for procedures between residency and fellowship programs.
Limitations
Our study has some limitations. The most important limitation is that our data are not longitudinal, as the case log

RESEARCH

experience is not that of the surveyed graduates. Another

limitation is the small sample size, both from the perspective of the number of surgical programs surveyed (2) and
the survey response rate among recent program graduates
(45%). The small number of respondents (19) introduces
the possibility of a type-II error, which may mean that a
stronger correlation between EC case volume and selfreported competence of graduates could actually exist (as
is predicted for SCORE EC cases). These limitations prevent us from making assumptions about the generalizability of our findings.

CONCLUSION
Our data offer a contemporary insight into the challenges of
creating a balanced educational curriculum in general surgery
that will meet the needs of future program graduates.
Competing interests: None declared.
Contributors: A. Safavi, M. Hameed and E. Skarsgard designed the
study. A. Safavi, S. Lai and M. Hameed acquired the data, which
A. Safavi, S. Butterworth, E. Skarsgard and D. Schiller analyzed.
A. Safavi and M. Hameed wrote the article, which all authors reviewed
and approved for publication.

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