Why Not This Case? Differences Between Resident and Attending Operative Cases at Teaching Hospitals

Area of Science:

• Surgical Education
• Patient Safety
• Health Services Research

Background:

• Previous research on resident operative autonomy has focused on outcomes, with limited analysis of patient and case characteristics influencing autonomy.
• Understanding the specific types of patients and surgical procedures where residents are granted autonomy is crucial for effective surgical training.

Purpose of the Study:

• To describe the differences in patient populations and surgical cases between those where residents are afforded operative autonomy and those where they are not.

Main Methods:

• Analysis of general and vascular operations from Veterans Affairs teaching hospitals (2004-2019) using the Veterans Affairs Surgical Quality Improvement Program.
• Categorization of resident supervision levels: attending primary (AP), attending resident (AR), and resident primary (RP).
• Evaluation of patient demographics, comorbidities, supervision level, and case complexity (work relative value unit) for each group.

Main Results:

• A total of 618,578 cases were analyzed, with 6.2% classified as resident primary (RP).
• Resident primary (RP) cases were less complex, involved younger patients with fewer comorbidities, and had a lower proportion of high-risk patients (ASA 3-5).
• Common RP cases included core general surgery procedures like hernia repair, cholecystectomy, and appendectomy, indicating focused skill development.

Conclusions:

• Residents are afforded autonomy primarily in less complex cases involving lower-risk patients, suggesting appropriate attending oversight.
• While this selection bias is appropriate, the learning potential in cases with sicker patients should not be overlooked for resident development.