Study: Surgical Residents Do Just Fine Without Close Supervision

Surgical patients were no more likely to die or suffer significant complications when their procedures were performed by residents without an attending surgeon present and ready to take over, an analysis of Veterans Affairs system data indicated.

All-cause mortality within 30 days was 1.2% both when attending surgeons were the primary operators and when residents filled that role, reported Joseph B. Oliver, MD, MPH, of the VA New Jersey Healthcare System in East Orange, and colleagues in JAMA Surgery.

Rates of post-procedural complications were 6.2% and 6.3%, respectively, in data covering more than 200,000 propensity-matched procedures. Statistically significant differences were seen for a few individual types of complications, but these were as likely to favor resident-alone procedures as those performed primarily by attendings, the researchers found.

Implications

"These data can be used to potentially reverse the pattern of decreasing resident autonomy," Oliver and colleagues wrote, citing a VA study from 2005 that found the proportion of surgical procedures performed mainly by residents had fallen by two-thirds in just the previous 6 years.

While it is obviously important for attending surgeons to ensure their residents are capable of working alone and that procedures are selected for them carefully, "the current status quo is not serving residents or current and future patients to the fullest extent," the researchers continued. "Efforts to increase surgical resident autonomy are needed because, as this study's findings suggest, resident autonomy and good patient outcomes are not incompatible."

In an invited commentary, three surgeons from the McGovern Medical School in Houston urged caution before turning residents loose in the operating room.

"[C]ompletion of an operation without an attending surgeon scrubbed is only the tail end of autonomy," noted the trio, led by Jonah Stulberg, MD, PhD. "Outside of technical assistance, attending faculty may also coach residents regarding next steps or provide advice to avoid missteps."

But they also agreed with Oliver's group that autonomy is vital for surgical residents so that they learn the necessary skills and, importantly, develop the confidence that all successful surgeons need.

"In fact, patient care ultimately will suffer if the training system is unable to produce competent surgeons who are independent in all domains: medical knowledge, decision-making, technical skills, and leadership," Stulberg and colleagues wrote. The goal for attendings, they suggested, is to provide enough "measured independence" for that to happen.

Study Details

Oliver and colleagues drew on data from the national VA system covering a total of 1.3 million procedures performed from 2004 to 2019.

Among these were about 140,000 performed by residents working alone and 308,000 performed primarily by attendings. The former were defined as those with codes indicating that an attending surgeon was present but not scrubbed in or otherwise ready to take over immediately. Attending-primary procedures were those coded specifically as being performed by the attending. (The majority, more than 800,000, had codes indicating that attendings were present and scrubbed in but the resident had performed "major portions"; these were classified as "resident plus attending.")

For the study's principal statistical comparison, the researchers matched about 101,000 resident-primary procedures to the same number of attending-primary surgeries, according to year of procedure, patient demographics and medical factors, and procedure type.

Although the means for patient characteristics in the two categories were not identical -- for example, 2.6% of patients operated on primary by surgeons has lost substantial weight in the previous 6 months versus 2.3% in resident-primary surgeries (P<0.001) -- no net bias in favor of resident-primary procedures was evident.

In addition to 30-day mortality and complication rates, Oliver's group also looked at rates of new surgeries within 30 days and median hospital stay and operative duration. Slightly fewer patients whose surgeries were performed mainly by attendings needed additional procedures (5.6% vs 6.0%, P<0.001) and their time on the table was shorter (median 70 vs 80 minutes, P<0.001); there was no difference in median hospital stay.

The researchers also compared outcomes for the resident-plus-attending procedures to those for resident-primary procedures. This analysis also showed no indication that the latter had worse outcomes.

As a retrospective records analysis, the study came with several limitations. Coding was somewhat subjective, Oliver and colleagues acknowledged, and the data did not capture every aspect of the included procedures, such as whether an attending stepped in to help even though he or she was not initially scrubbed in. Also, the propensity-matching was probably imperfect.

The researchers called the 15-year time frame for the study both a strength (it provided a large number of procedures for analysis) as well as a limitation, insofar as factors influencing the study's outcomes likely changed over time. In particular, the group argued that residents' average skill level may have decreased during this period in line with their diminished autonomy.

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