A. J. Sehat1, Y. Yu2, A. Kunac2, J. B. Oliver2, D. J. Anjaria2 1Rutgers Health New Jersey Medical School, Department Of Surgery, Newark, NJ, USA 2Veterans Administration New Jersey Health Care System, Department Of Surgery, East Orange, NJ, USA
Introduction: Surgical resident operative autonomy has decreased markedly over time with increasing scrutiny on OR efficiency, quality, and outcomes. Decreased autonomy is one of the reasons cited for decreasing resident readiness for independent practice. We sought to examine the change in operative resident autonomy for emergency ACS cases over time and outcomes relative to operative autonomy.
Methods: Utilizing the VASQIP database, we examined all ACS cases (emergency general, vascular, and thoracic) at all Veterans Administration (VA) hospitals from 2004-2019. All cases at the VA are coded for level of supervision at the time of surgery: (AP) attending primary surgeon; (AR) attending and resident both operating and (RP) resident primary (attending supervising but not scrubbed). Baseline demographics, operative variables, and outcomes were compared between groups.
Results: Over the 15-year study period, 66,008 total ACS cases were performed (79% general, 18% vascular, 3% thoracic); with 28% AP, 65% AR and 7% RP. From 2004 to 2019, the proportion of ACS RP cases decreased from 9.9 to 4.1%; during the same period, elective RP cases decreased from 8.9% to 2.9%. The most common ACS RP surgeries were appendectomy (24% lap, 5% open), amputations (6% guillotine BKA, 3% AKA, and 2% BKA), and cholecystectomy (5% lap, 1% open). RP cases had less severe comorbidities compared to AP and AR comparing ASA class. There was no difference in mortality between supervision groups even after adjusting for comorbidities. Adjusted morbidity was higher in AR compared to AP (OR 1.16 (1.11-1.22)), with no difference for RP cases. Adjusted return to OR was higher in AR compared to AP (OR 1.08 (1.02-1.14)) with no difference for RP cases.
Conclusion: ACS cases showed a significant decrease in resident autonomy over the past 15 years; this decrease is comparable to the decrease in elective cases over the same time frame. Resident autonomy, even when adjusted for comorbidities, does not negatively impact outcomes. While the decline in resident autonomy has not improved patient outcomes even in emergency cases; it does negatively impact surgical education. Therefore, it is imperative we allow operative autonomy to better prepare graduating residents for independent practice.
