Urology Resident Autonomy in the Veterans Affairs Healthcare System

Surgical resident autonomy in procedures has been eroding over time, due to multiple factors that include duty hour restrictions, focus on operating time, complication rate, and trust among supervising physicians. This study examines whether urology residents at the Veterans Affairs hospitals (VA) have experienced decreased surgical autonomy and contributing factors.

The national VA Surgical Quality Improvement Program (VASQIP) was queried for the most common urologic procedures between 2004 to 2019 with resident involvement. The most frequent surgeries were transurethral resection of prostate (TURP); transurethral resection of small, medium, or large tumor (TURBT); photo vaporization of prostate, scrotal surgery, and ureteral stent placement. The cases were stratified by resident involvement: attending as primary (AP), attending and resident (AR), resident as primary (RP).

93,756 urology cases were selected from 2004 to 2019. The above procedures accounted for 76.5% of all urologic cases. The percentage of RP cases decreased from 44.4% of cases in 2004 to 25.1% in 2019. Reduction in RP cases was seen in all of the 7 examined urology cases. Cases with resident involvement had patients with more medical comorbidities. Mean operative times were not significantly different. The 30-day composite complications and 30-day return to operating room were greatest for AR. Postoperative morbidity and all-cause mortality were not significantly different.

Urology resident autonomy has decreased within the VA healthcare system over the past 15 years. Mean operative times and postoperative complications are not significantly different in cases with residents as primary surgeon.