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

Area of Science:

• Medical Education
• Surgical Training
• Healthcare Quality Improvement

Background:

• Previous research indicates a general decline in resident autonomy over time.
• Operative autonomy is a critical component of surgical skill development and resident training.

Purpose of the Study:

• To examine trends in operative autonomy among general surgery residents at each postgraduate year (PGY) level.
• To assess how changes in operative autonomy correlate with procedure complexity and resident experience.

Main Methods:

• Retrospective analysis of the Veterans Affairs Surgical Quality Improvement Program database (2004-2019).
• Inclusion of general surgery, vascular surgery, and thoracic surgery procedures.
• Categorization of procedures by resident supervision level and use of relative value unit (RVU) for complexity assessment.

Main Results:

• Analysis of 385,482 cases revealed a significant decrease in resident-performed primary cases across all PGY levels (PGY 4: -37.3%, PGY 3: -75.5%).
• Mean procedure complexity, measured by RVU, increased with PGY level but showed no trend over time.
• The decline in resident autonomy was observed consistently from 2014 to 2018.

Conclusions:

• Surgical resident operative autonomy has markedly decreased over time, particularly impacting PGY 3 residents.
• Increased procedure complexity aligns with PGY level, but does not explain the observed decrease in autonomy.
• The findings highlight a critical trend affecting surgical education and the development of independent surgical skills.