Project

Characterization of surgical resident operative autonomy

Goal: Surgical educators have been discussing that residents are less prepared and afforded less autonomy than “when we were in training.” Prior literature with surveys of residents, faculty, and even fellowship program directors showed a decreasing readiness for independent practice. While the reasons for this decline are multifactorial, there is no doubt that it has an impact on the readiness of graduating surgical residents for practice. Literature examining the effect of residents in surgical cases has either been limited as NSQIP only records whether a resident was scrubbed, not what level of attending supervision versus autonomy was present. I found the VASQIP database had the data fields to overcome these limitations. Subsequently, we have undertaken a thorough examination to document the degree of decline in resident autonomy, outcomes with cases in which the resident is afforded autonomy as well as factors associated with resident autonomy cases.

Date: 1 July 2020

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Devashish Anjaria
added a project goal
Surgical educators have been discussing that residents are less prepared and afforded less autonomy than “when we were in training.” Prior literature with surveys of residents, faculty, and even fellowship program directors showed a decreasing readiness for independent practice. While the reasons for this decline are multifactorial, there is no doubt that it has an impact on the readiness of graduating surgical residents for practice. Literature examining the effect of residents in surgical cases has either been limited as NSQIP only records whether a resident was scrubbed, not what level of attending supervision versus autonomy was present. I found the VASQIP database had the data fields to overcome these limitations. Subsequently, we have undertaken a thorough examination to document the degree of decline in resident autonomy, outcomes with cases in which the resident is afforded autonomy as well as factors associated with resident autonomy cases.
 
Devashish Anjaria
added a research item
OBJECTIVE: The volume of cases that residents perform independently have decreased leaving graduating chief residents less prepared for independent practice. Outcomes are not worse when residents are given autonomy with appropriate supervision, however it is unknown if outcomes are worsening with decreasing operative autonomy experience. We hypothesize that resident autonomous cases parallel the improving outcomes in surgical care over time, however, are less complex and on lower acuity patients. DESIGN: Retrospective study utilizing the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. SETTING: Operative cases performed on teaching services within the VASQIP database from July 1, 2004 to September 30, 2019, were included. PARTICIPANTS: All adult patients who underwent a surgical procedure from July 1, 2004, to September 30, 2019, at a VA hospital on a service that included residents were initially included. After inclusions and exclusions, there were 1,346,461 cases. Cases were divided into 3 sequential 5 year eras (ERA 1: 2004-2008, n = 415,614, ERA 2: 2009-2013 n = 478,528, and ERA 3:2014-2019 n = 452,319). The main exposure of interest was level of resident supervision, coded at the time of procedure as: attending primary surgeon (AP); attending and resident (AR), or resident primary with the attending supervising but not scrubbed (RP). We compared 30 day all-cause mortality, composite morbidity, work relative value unit (wRVU), hospital length of stay, and operative time between each ERA for RP cases, as well as within each ERA for RP cases compared to AR and AP cases. RESULTS: There was a progressive decline in the rate of RP cases in each successive ERA (ERA 1: 58,249 (14.0%) vs ERA 2: 47,891 (10.0%) vs ERA 3: 35,352 (7.8%), p < 0.001). For RP cases, patients were progressively getting older (60 yrs [53-71] vs 63 yrs [54-69] vs 66 yrs [57-72], p < 0.001) and sicker (ASA 3 58.7% vs 62.5% vs 66.2% and ASA 4/5 8.4% vs 9.6% vs10.0%, p < 0.001). Odds of mortality decreased in each ERA compared to the previous (aOR 0.71 [0.62-0.80] ERA 2 vs ERA 1 and 0.82 [0.70-0.97] ERA 3 vs ERA 2) as did morbidity (0.77 [0.73-0.82] ERA 2 vs ERA 1 and 0.72 [0.68-0.77] ERA 3 vs ERA 2). Operative and length of stay also decreased while wRVU stayed unchanged. When comparing RP cases to AP and AR within each ERA, RP cases tended to be on younger and healthier patients with a lower wRVU, particularly compared to AR cases. Mortality and morbidity were no different or better in RP compared to AR and AP. CONCLUSIONS: Despite resident autonomy decreasing, outcomes in cases where they are afforded autonomy are improving over time. This despite RP cases being on sicker and older patients and performing roughly the same complexity of cases. They also continue to perform no worse than cases with higher levels of supervision. Efforts to increase surgical resident operative autonomy are still needed to improve readiness for independent practice.
Devashish Anjaria
added 14 research items
OBJECTIVE Resident operative autonomy has been steadily declining. The reasons are multifactorial and include concerns related to patient safety and operating room efficiency. Simultaneously, faculty have expressed that residents are less prepared for independent practice. We sought to understand the effect of decreasing resident autonomy on patient outcomes and operative duration. DESIGN Retrospective study utilizing the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. SETTING Operative cases within the VASQIP database from July 1, 2004-September 30, 2019 were analyzed. PARTICIPANTS All adult patients who underwent a surgical procedure from July 1, 2004 to September 30, 2019 were analyzed. The subpopulation of patients that underwent a surgical procedure in General Surgery or Peripheral Vascular Surgery were identified based on the code of the specialty surgeon. Within these subgroups, the most frequent cases by current procedural terminology (CPT) code were selected for study inclusion. The principle CPT code of all cases was further coded by level of supervision: attending primary surgeon (AP); attending and resident (AR), or resident primary with the attending supervising but not scrubbed (RP). Baseline demographics, operative variables, and outcomes were compared between groups. RESULTS The VASQIP database included 698,391 total general/vascular surgery cases. 38,483 (6%) of them were RP cases. Analysis revealed that the top 5 RP cases account for 73% of total RP volume–these include: 1) Hernias (55% total; 33% open inguinal, 13% umbilical, 5% open ventral/incisional, and 4% laparoscopic) 2) cholecystectomy (18%), 3) Amputations (17% total; 10% above knee, 7% below knee), 4) Appendectomy (7%) and 5) Open colectomy (3%). The percentage of cases at teaching hospitals that were RP cases significantly decreased from 15% in 2004 to 5% in 2019 (p < 0.001). RP cases were generally sicker as demonstrated by higher ASA classifications and more likely to be emergent cases. Operative times were also increased with resident involvement, but RP cases were faster than AR cases on average. After adjusting for baseline demographics, case type, and year of procedure, mortality was no different between groups. Complications were higher in the AR group but not in the RP group. CONCLUSIONS The rate of resident autonomy in routine general surgery cases has decreased by two-thirds over the 15-year study period. Cases performed by residents without an attending surgeon scrubbed were performed faster than cases performed by a resident and attending together and there was no increase in patient morbidity or mortality when residents performed cases independently. The erosion of resident autonomy is not justified based upon operative time or patient outcomes. Efforts to increase surgical resident operative autonomy are needed.
Background Examining surgical resident operative autonomy within the Veterans Affairs (VA) System, we previously showed residents were afforded autonomy more frequently on Black patients. We hypothesized that, compared to males, female surgical patients receive less attending involvement and more resident autonomy during surgery. Methods Retrospective review of all general/vascular surgeries performed at teaching VA hospitals from 2004 to 2019. Operative procedures are coded at the time of surgery as attending primary surgeon (AP), attending with resident (AR), or resident primary surgeon--attending not scrubbed (RP). The primary outcome was the difference in supervision rates between patient sexes. Results 618,578 operations were examined—24.9% AP, 68.9% AR, and 6.2% RP. Overall, 5.9% of cases were performed on women. The rate of RP cases was higher in males compared to females (6.3% vs 5.3%, p < 0.001). Conclusion Female veterans are less likely to have residents operate on them autonomously. Reasons for this require further characterization.
Devashish Anjaria
added a research item
Introduction With improved technology and technique, laparoscopic inguinal hernia repair (LIHR) has become a valid option for repairing both initial and recurrent inguinal hernia. Surgical residents must learn both techniques to prepare for future practice. We examined resident operative autonomy between LIHR and open inguinal hernia repair (OIHR) across the Veterans Affairs (VA) system. Methods Utilizing the VA Surgical Quality Improvement Program database, we examined inguinal hernia repairs based on the principal procedure code at all teaching VA hospitals from July 2004 to September 2019. All VA cases are coded for level of supervision at the time of surgery: attending primary surgeon (AP); attending scrubbed but resident is a primary surgeon (AR), and resident primary with attending supervising but not scrubbed (RP). Primary outcomes were the proportion of LIHR versus OIHR and resident autonomy over time. Results A total of 127,497 hernia repair cases were examined (106,892 OIHR and 20,605 LIHR). There was a higher proportion of RP (8.7% vs 2.2%) and lower proportion of AP (23.9% vs 28.4%) within OIHR compared to LIHR (p < 0.001). The overall proportion of LIHR repairs increased from 9 to 28% (p < 0.001). RP cases decreased for LIHR from 9 to 1% and for OIHR from 17 to 4%, while AP cases increased for LIHR from 16 to 42% and for OIHR from 18 to 30% (all p < 0.001). For RP cases, mortality (0 vs 0.2%, p > 0.99) and complication rates (1.1% vs. 1.7%, p = 0.35) were no different. Conclusions LIHR at VA hospitals has tripled over the past 15 years, now compromising nearly one-third of all inguinal hernia repairs; the majority are initial hernias. Despite this increase, resident autonomy in LIHR cases declined alarmingly. The results demonstrate an urgent need to integrate enhanced minimally invasive training into a general surgery curriculum to prepare residents for future independent practice. Graphical abstract