Career Phase of Board Certified General Surgeons: Workload Composition and Outcomes

Forty six million surgeries performed annually support the need to improve surgical outcomes. A high correlation between surgical volume and improved patient outcomes is well-established. Limited research is available on surgeon workload composition and outcomes at different career phases. The study examines surgical volume and surgeon experience since board certification to assess any potential association with morbidity and mortality.

Data from the 2004-2006 Florida Patient Discharge Database were linked to Practitioner Profile data provided by the Florida Department of Health, using unique surgeon identifiers. Date of board certification was obtained from the American Board of Surgery (ABS) online database. ABS certified General Surgeons (n=1,187) were grouped into four career phases based on years since board certification (<10 years[early], 10-19 years[early mid], 20-29 years[mid], ≥30 years[late]). Practice composition, complication and mortality rates were examined for each surgeon cohort performing total of 460,881 procedures on adults aged 18 and older.

Analyses included chi-square and trend tests and generalized estimating equations to accommodate nesting. Analyses were adjusted for patient age, ethnicity, insurance type, comorbidities, hospital ownership and surgeon and hospital volume. Risk adjustment was performed using the Agency for Healthcare Research and Quality co-morbidity software (Elixhauser et al. 1998).

The largest percentage of general surgeons had been board certified for 10-19 years (38%) or 20-29 years (27%). The percentage of surgeons in early or late career phase was 19% and 16% respectively. Most surgeons (90.3%) practiced in a metropolitan area. Average surgical volume was lowest among late career phase surgeons (227.0/surgeon) and highest among surgeons in early mid-career (449.5/surgeon). Surgeries involving the digestive and cardiovascular systems formed the largest proportion (74.4%) for all surgeon categories. The percentage of cardiovascular surgeries increased with career phase (p<0.001), while the inverse was true for digestive surgeries (p<0.001). The risk of complications from cardiovascular surgeries was higher for surgeons in early (RR: 1.28, 95% CI: 1.12-1.47) and mid-career phase (RR: 1.16, 95% CI: 1.02-1.33). The risk of mortality for cardiovascular procedures was also higher for early career surgeons (RR: 1.22, 95% CI: 1.01-1.46). Differences for digestive surgeries were not statistically significant.

Findings suggest that longer surgical experience and increasing specialization is associated with better outcomes. Cumulative surgical volume could be a better indicator for improved outcomes, as compared to cross-sectional volume.

The study provides insight in surgeon career phase and its impact on case load, surgical volume and outcomes, a largely understudied area of research.