COVID-19 Surgical Case Log FAQs [to supplement the memo to PDs now published]

Question 1:
Our sponsoring institution has declared a "Stage 3: Pandemic Emergency Status". Will the 2020 graduates of our program have to meet the case minima established by the Review Committee?
Answer:
The Review Committee uses the case log minima as one metric in determining the accreditation status of a program. Case log data has been and will be collected throughout the years that the resident/fellow is in the program. Therefore, despite most program requirements being suspended for the duration of a Pandemic Emergency Status, the Review Committees will not waive case log minima in making accreditation decisions. Rather, they will be interpreted and applied in light of the impact of the pandemic on a program as expressed in the "Major Changes and Other Updates" section of that programís ADS Annual Update. Whether or not a resident/fellow has achieved all the case minima, the program director (with input from the Clinical Competence Committee) must decide whether that individual is ready to graduate from the program by virtue of being capable of practicing safely without supervision.

Question 2:
Our program is in "Stage 2: Increased Clinical Demands". Will the 2020 graduates of our program have to meet the case minima established by the Review Committee?
Answer:
The Review Committee uses the case log minima as one metric in determining the accreditation status of a program. Case log data has been and will be collected throughout the years that the resident/fellow is in the program. The case log minima will not be waived by the Review Committees in making accreditation decisions. Rather, they will be interpreted and applied in light of the impact of the pandemic on a program as expressed in the "Major Changes and Other Updates" section of that programís ADS Annual Update.

Whether or not a resident/fellow has achieved all the case minima, the program director (with input from the Clinical Competence Committee) must decide whether that individual is capable of practicing safely without supervision.

Question 3:
During this time of crisis, do the residents/fellows in surgical programs need to continue to enter their cases in the ACGME case log system?
Answer:
Case logs were created- and minima were established for- the purpose of program accreditation. Review Committees will to use the case logs of 2019-2020 graduates and the minima in accreditation decisions in 2021. Those data will be interpreted and applied in light of the impact of the pandemic on a program as expressed in the "Major Changes and Other Updates" section of that programís ADS Annual Update.

Although they were created for program accreditation, the case logs have secondary uses beyond that purpose. A small but growing number of certifying boards utilize resident case logs in determining eligibility for the certification process. Graduates of surgical programs also utilize their residency/fellowship case logs in applications for hospital and other clinical privileges.

Whether they are to be used in accreditation, certification or privileging it is, therefore, certainly desirable for residents/fellows to track all the procedures that they perform. This would seem particularly important during the pandemic when many types of cases that are normally available are so diminished in number.

Question 4:
Can a resident/fellow graduate from a surgical program without having achieved all the case minima?
Answer:
Yes. The case minima were established- and are used for purposes of program accreditation. They were never intended to stand as a surrogate for the technical competence of an individual and should not be utilized in that way. Whether or not a resident/fellow has achieved all the case minima, the program director (with input from the Clinical Competence Committee) must decide whether that individual is capable of practicing safely without supervision.

Please note that while graduation from an ACGME-accredited program is required for an individual to enter the certification process, simply graduating does not ensure that the individual will meet all criteria to enter the certification process. Questions regarding eligibility to enter the certification process should be directed to the appropriate certifying board.

Question 5:
Could my program be given a status of Continued Accreditation with Warning because the residents/fellows did not achieve some of the case minima as a result of the pandemic?
Answer:
A Review Committee decision to confer a status of Continued Accreditation with Warning is based on a thorough review of all available program data and the conclusion that a program has areas of non-compliance that may jeopardize its accreditation status. The case log minima are one metric used in determining the accreditation status of a program but in 2021 they will be reviewed in light of the impact of the pandemic on a program as expressed in the "Major Changes and Other Updates" section of that programís ADS Annual Update.

Question 6:
Elective surgery has already been cancelled in our institution for two weeks and may not be resumed for months. The vast majority of the cases that our residents usually record are elective. The number of cases recorded by our graduating residents will be lower this year than at any time in the past and most of them will not achieve all case minima. Will our program be put on probation because of that?
Answer:
The decision of a Review Committee to confer Probationary Accreditation to a program is based on a thorough review of all available program data and the conclusion that a program has failed to demonstrate substantial compliance with the requirements. It is typically the result multiple serious deficiencies extending over multiple years. The Review Committees recognize that the impact of the pandemic is unprecedented, time-limited and far beyond the control of the program. The case log minima will not be waived by the Review Committees in making accreditation decisions. However, the case logs of the 2020 graduates will be reviewed in light of the impact of the pandemic on a program as expressed in the "Major Changes and Other Updates" section of that programís ADS Annual Update.

Question 7:
The only cases available to our residents right now are the occasional emergency operations. The residents who are scheduled to graduate in 2020 have already done more than enough cases. My concern is that the residents scheduled to graduate in 2021 will not even be able to achieve the minimums. Will our program be cited if they donít?
Answer:
Graduate case logs are used in making accreditation decisions for established programs. Those case logs, of course, contain operations performed throughout all years of the program. The Review Committees are aware of the impact of the COVID-19 pandemic on the number of elective operations now available and that the absence of those cases will, to a greater or lesser extent, affect the number of operations performed by residents in every PGY level. Thus, the effects of even a small number of months of absence of elective operations may cascade through a few years of graduate case logs. In making accreditation decisions (including the issuance of citations) each Review Committee will consider the impact of the pandemic on a program as expressed in the "Major Changes and Other Updates" section of that programís ADS Annual Update. Whether or not a resident/fellow has achieved all the case minima, the program director (with input from the Clinical Competence Committee) must decide whether that individual is ready to graduate from the program by virtue of being capable of practicing safely without supervision.

Question 8:
The vast majority of the cases that our residents perform are elective. It appears likely that elective surgery at our institution will not be resumed for several months. Should we start thinking about recruiting fewer residents in 2021 so we that our current residents and those starting in July will have enough cases to meet their minima in future years?
Answer:
The current priority is for residents, fellows and faculty members to fulfill their moral obligation as physicians to do their part in treating the victims of the pandemic. The decision about the number of residents/fellows to recruit in 2021 is (at this writing) several months in the future. By the time that decision must be made, the program will be much more able to assess the impact of the pandemic on the volume and variety of cases performed by currently enrolled residents/fellows and the cascading effects on future enrollees.

Question 9:
Once surgical volume begins to increase as the pandemic abates, how do we balance the educational needs of the core residency program with those of the co-located fellowship programs?
Answer:
These are decisions that can only be made at the program level based on resources (i.e., cases) available and competing interests (i.e., programs, residents and fellows) for those resources. The program director of the core residency and the program director(s) of the fellowship program(s) should work together to thoughtfully prioritize the assignment of operative cases as they become available. In doing so, they should consider maximizing the learning opportunities by allowing fellows to act in the role of teacher for the residents whenever appropriate. Of paramount importance is that the program directors have an obligation to the public and to the residents/fellows to graduate only those whom they can verify as having demonstrated the knowledge, skills and behaviors necessary to enter autonomous practice.