Declining Surgical Resident Operative Autonomy in Acute Care Surgical Cases

Surgical resident operative autonomy has decreased markedly over time, reducing resident readiness for independent practice. We sought to examine operative resident autonomy for emergency acute care surgery (ACS) compared to elective cases and associated patient outcomes at veterans affairs hospitals.

The Veterans Affairs Surgical Quality Improvement Program database was queried for ACS cases (emergency general, vascular, and thoracic) at veterans affairs hospitals from 2004 to 2019. Cases are coded prospectively for the level of supervision: attending primary surgeon (AP); attending scrubbed with resident surgeon (AR); resident primary (RP), attending not scrubbed. Baseline demographics, operative variables, and outcomes were compared.

A total of 61,275 ACS cases and 605,146 elective cases were performed during the study period. The ACS had a higher proportion of RP cases (7.2% versus 5.7%, P < 0.001). The proportion of ACS RP cases decreased from 9.9% to 4.1% (58.6%); elective RP cases decreased from 8.9% to 2.9% (67.4%). The most common ACS RP surgeries were appendectomy, amputations, and cholecystectomy. RP cases had lower American Society of Anesthesia class and lower median work relative value units than AP and AR. There was no difference between mortality rates of RP compared to AP (adjusted odds ratio [OR] 0.94 [0.80-1.09] or AR 0.94 [0.81-1.08]). While there was no difference in complications between the RP and AP (OR 1.01 [0.92-1.12]), there were significantly more complications in AR compared to RP (OR 1.20 [1.10-1.31]).

More autonomy is granted for ACS cases compared to elective cases. While both decreased over time, the decrease is less for ACS cases. Resident autonomy does not negatively impact outcomes, even in emergent cases.