Declining Surgical Resident Operative Autonomy-All Trainees Are Not Created Equal

We have previously shown that resident autonomy has decreased over time overall for all surgery residents. The purpose of this study is to examine changes in operative autonomy in general surgery residency within each postgraduate year (PGY) level.

This is a retrospective analysis of the Veterans Association Surgical Quality Improvement Program database from July 1, 2004 to September 30, 2019. All general surgery, vascular surgery, and thoracic surgery procedures were analyzed and categorized by level of resident supervision as attending primary, attending operating with resident, or resident primary without attending scrubbed. Procedure work portion of relative value unit was used to capture procedure complexity. Changes in resident autonomy over time, procedure complexity, and outcomes were compared among PGY levels 1 to 5.

A total of 385,482 cases were analyzed. At each PGY level from 2014 to 2018, the relative decrease in resident primary cases ranged from -37.3% (PGY 4) to -75.5% (PGY 3). Mean work portion of relative value unit saw steady increase with PGY level (8.4 ± 3.5 in PGY 1 to 10.8 ± 5.7 in PGY 5, P < 0.001) and did not show a trend over time.

Surgical resident operative autonomy has markedly decreased over time across all PGY levels. This effect is most profound at the PGY 3 level, while more senior residents are affected to a lesser degree. Case complexity show PGY level-appropriate increase in resident autonomous cases. Decrease in resident autonomy over time is not associated with changes in case complexity.