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Declining Resident Surgical Autonomy and Improving Surgical Outcomes: Correlation Does Not Equal Causality.

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Surgical resident autonomy in performing cases has decreased, yet patient outcomes in these autonomous cases have improved over time. This trend persists even with older, sicker patients, indicating a need to increase resident operative autonomy for better practice readiness.

Keywords:
Residentautonomyentrustable professional activitiesoutcomessurgical education

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Area of Science:

  • Surgical Education
  • Patient Outcomes
  • Healthcare Quality Improvement

Background:

  • Surgical resident operative autonomy has declined, potentially impacting preparedness for independent practice.
  • Previous studies suggest patient outcomes are not worse with resident autonomy under supervision.
  • The impact of decreasing operative autonomy on surgical outcomes remains unclear.

Purpose of the Study:

  • To investigate trends in resident autonomous surgical cases over time.
  • To evaluate patient outcomes associated with decreasing resident operative autonomy.
  • To compare outcomes of resident primary (RP) cases with attending primary (AP) and attending-resident (AR) cases.

Main Methods:

  • Retrospective study using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database (2004-2019).
  • Analyzed 1,346,461 operative cases across three 5-year eras.
  • Compared 30-day mortality, morbidity, wRVU, length of stay, and operative time based on resident supervision level (AP, AR, RP).

Main Results:

  • Resident primary (RP) cases significantly decreased across eras (14.0% to 7.8%).
  • Patients in RP cases became older and sicker over time (p < 0.001).
  • Mortality and morbidity decreased in RP cases across eras, with no difference or improvement compared to AR and AP cases.

Conclusions:

  • Despite declining autonomy, outcomes for resident-performed cases have improved.
  • RP cases are performed on older, sicker patients with similar complexity, yet yield comparable or better outcomes.
  • Increased surgical resident operative autonomy is crucial for enhancing readiness for independent practice.