Are Urology Residents Losing Autonomy? A National Analysis of ACGME Case Log Data from 2013 to 2023

To examine national trends in urology resident surgical autonomy using Accreditation Council for Graduate Medical Education (ACGME) case log data.

A retrospective cohort analysis of ACGME case logs for all graduating urology residents from 2013 to 2023. Resident-defined operative role ("assistant," "surgeon," or "teaching assistant") was used as a proxy for surgical autonomy, and an autonomy score was calculated for each resident. Trends over time were evaluated using mixed-effects regression, and differences by procedure subtype, ERAS geographic region, and sex were assessed using analysis of variance.

A novel national database encompassing all urology residency programs across the United States.

Graduating urology residents who completed ACGME-accredited urology residency programs between 2013 and 2023. A total of 3391 residents across 145 programs met inclusion criteria.

Mean case number per resident increased from 1243 in 2013 to 1404.6 in 2023 (p < 0.001). Mean autonomy score declined significantly over the study period from 92% in 2013 to 85% in 2023 (p < 0.001). Autonomy varied significantly according to procedure subtype, with oncology demonstrating the lowest autonomy at 78%, and endourology and general urology demonstrating the highest autonomy at 94% and 93%, respectively (p < 0.001). Autonomy varied significantly by ERAS geographic region (p < 0.001) and sex, with males reporting higher autonomy scores than females (p < 0.001).

This national cohort analysis demonstrates a significant and sustained decline in urology resident self-reported surgical autonomy, with variation according to procedure subtype, geographic region, and sex. These findings are concerning and highlight the importance of re-evaluating and prioritizing autonomy within urology residencies.