Purpose: The educational goal of a plastic surgery training program is to produce competent surgeons, but how do we evaluate surgical competency, which requires assessment of knowledge, technical skill, and judgment? Although the volume-outcome relationship is well established for such procedures as coronary artery bypass grafting and hip replacement, less is known about procedural “learning curves” and the development of competence, especially in plastic surgery. This study investigates the relationship between case volume, medical knowledge, and surgical competence in plastic surgery residents, at a single institution, over the past decade.

Methods: Competency in plastic surgery residents was assessed by inspection of operative logs reported to Residency Review Committee, performance on the in-service examination, query of semi-annual resident evaluations, and board certification. Total case volume, as well as number of specific procedures, was assessed over time. In-service examination performance was evaluated using percentile scores. Groups were compared using unpaired, two-tailed t tests and correlation coefficients. Statistical significance was defined for p values < 0.05.

Results: From 1992-2004, 22 residents started and successfully completed training in plastic surgery at a fully-accredited, two-year, independent program, at a university teaching hospital in the Southeast. The case volume of the finishing residents increased dramatically during this period, from a mean of 1208 cases in 1994 to 2194 cases in 2004 (r2=0.61). Assessment of case volume for specific procedures over time showed no significant change in facelift procedures, decrease in free tissue transfer over the past five years, and continued increase in breast reconstruction and palatoplasty. Despite residents meeting the RRC minimum requirements in nearly all categories, there did exist significant resident variability in these categories, throughout the study period. In terms of medical knowledge, case volume and in-service examination scores did not show any correlation (r2=0.02). Interestingly, residents who pursued fellowships finished with more cases than residents who went directly into practice (2053 vs 1491 cases, p=0.05). In-service examination scores were nearly identical, with residents who pursued fellowships scoring at the 50th percentile and residents who went directly into practice scoring at the 49.8th percentile. Finally, 21/22 residents have passed the Qualifiying Examination of the American Board of Plastic Surgery, and 17/22 residents are currently board certified by the Amercian Board of Plastic Surgery, with four scheduled to take the oral examination this year.

Conclusions: Surgical competence in residents is difficult to measure and must therefore be assessed by multiple instruments, such as case volume, in-service examination scores, faculty evaluations, and board certification. Resident case volume most likely contributes to surgical competence but is not a good predictor of medical knowledge. Furthermore, minimum case numbers necessary to produce surgical competence remain unknown, despite established requirements of the RRC. Periodic, longitudinal assessment of resident case logs by the Program Director and Surgical Education Committee is critical to ensure that index categories continue to be well-represented and evenly distributed, and that case volume is matched by case quality.
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