Surgical Residents' Autonomy Declining at US VA Hospitals

By Linda Carroll

November 29, 2021

NEW YORK (Reuters Health) - Over a 15-year period, the number of cases in which surgical residents are listed as primary has been dropping at Veterans Affairs Hospitals, a new study finds.

Meanwhile, cases where an attending surgeon performs the operation increased between 2004 and 2019, researchers report in JAMA Surgery.

"The goal of surgical residency is to ready future surgeons for independent practice," said the study's first author, Dr. Devashish Anjaria, chief of surgery at Veterans Affairs New Jersey Health Care System, in East Orange. "Part of that training is a gradual increase in what the resident is allowed to do in the operating room with the eventual goal of allowing a resident to perform selected procedures without the attending scrubbed but directly supervising in the operating room as a final stepping stone towards practicing independently."

"Despite this critical step in the evolution to a fully trained surgeon, our study shows that over a 15 year period, the proportion of cases that allow this supervised independence has dropped by two-thirds overall, and in some surgical specialties by up to 86%!" Dr. Anjaria, also at Rutgers New Jersey Medical School, told Reuters Health by email.

He compared resident surgical training to the process by which teenage student drivers get more practice and experience with their parents in the car watching over to make sure all is done safely.

"With the decreasing autonomy in the OR for surgical residents that we have shown, surgical trainees are not having as many chances to 'drive with Mom or Dad present' but they will still be free for independent practice at the end of residency. This is a significant factor for why prior research from others has shown that graduating surgical residents and their faculty feel that graduating residents are less prepared for independent practice than in years' past and may be one reason why so many surgical residents will pursue fellowship training after residency."

To take a closer look at trends in resident surgical training, Dr. Anjaria and his colleagues conducted a cross-sectional study using the Veterans Affairs Surgical Quality Improvement Program database on patients undergoing surgery at Veterans Affairs Medical Centers between 2004 and 2019.

After excluding cases that were done at nonteaching hospitals, the researchers were left with close to 1,361,000 surgical cases to include in their analysis. During the study period, the percentage of cases where the attending was primary increased from 16.8% to 31.0%.

The percentage of cases during which both the attending and the resident scrubbed in declined from 67.1% to 62.9%. And the percentage of cases where the resident was primary decreased from 16.1% to 6.1%. Cases in which the attending was not in the operating room but in the operating suite dropped from 2.1% to 0.3%.

All changes were statistically significant.

"Many efforts are already being done to remedy the lack of confidence, such as increased simulation," Dr. Anjaria said. "However, no amount of simulation prepares you for the real world exactly. The surgical community as well as the public want the best possible outcomes for patients, and we want to increase independence for residents while maintaining excellent outcomes."

"The next step we are working on is looking at outcomes on cases with appropriately selected patients with an attending surgeon present in the room but not scrubbed and seeing if they have the same outcome as cases where the attending is scrubbed with the resident." he said. "Once we show that allowing the residents to operate with a surgeon not scrubbed but supervising in the room is safe with no increase in complications, we can start the dialog for creating a model for allowing more supervised independence in the operating room to ensure good outcomes while improving the education of future surgeons.

SOURCE: JAMA Surgery, online November 17, 2021