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Jones-Carr ME, McLeod C, Baker S, Lindeman B. Framing our Expectations: Variability in Entrustable Professional Activity Assessments. JOURNAL OF SURGICAL EDUCATION 2024; 81:1355-1361. [PMID: 39163720 DOI: 10.1016/j.jsurg.2024.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/30/2024] [Accepted: 07/28/2024] [Indexed: 08/22/2024]
Abstract
OBJECTIVE To determine the ability of surgical trainees and faculty to correctly interpret entrustability of a resident learner in a modeled patient care scenario. DESIGN Prospective study utilizing a web-based survey including 4 previously-recorded short videos of resident learners targeted to specific levels of the American Board of Surgery's (ABS) Entrustment Scale. Respondents were asked to choose the entrustment level that best corresponded to their observations of the learner in the video. Responses were subcategorized by low and high entrustment. SETTING Online, utilizing the Qualtrics survey platform. PARTICIPANTS Survey targeting US surgical trainees and surgical faculty via email and social media. We received 31 complete responses and 2 responses which completed > 1 video assessment question without demographic information (n = 33). Respondents included 10 trainees (32%) and 21 attending surgeons (68%). RESULTS Neither faculty nor trainees readily identified the targeted entrustment level for Question 1 (preoperative care of a patient with acute appendicitis with high entrustment, 36% correct), though evaluations of the remaining questions (2 through 4) demonstrated more accuracy (70, 84, and 75% correct, respectively). Faculty were more readily able than trainees to identify low entrustment (level Limited Participation) in intraoperative inguinal hernia repair (95% vs 60%, p = 0.03). After subcategorization to high and low entrustment, both residents and faculty were able to accurately identify entrustment 95% overall. CONCLUSIONS Both trainees and attending surgeons were able to identify high- and low-performing residents on short video demonstrations using the ABS EPA entrustment scale. This provides additional evidence in support of the need for frequent observations of EPAs to account for the variability in raters' perceptions in addition to complexity of clinical scenarios. Frame-of-reference training via a video-based platform may also be beneficial for both residents and faculty as an ongoing EPA implementation strategy.
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Affiliation(s)
| | - Chandler McLeod
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Samantha Baker
- Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Brenessa Lindeman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL.
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2
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Grimsley EA, Anderson DO, Kendall MA, Zander T, Parikh R, Weigel RJ, Kuo PC. For the Love of the Game: Calculating the Premium Associated With Academic Surgical Practice. Ann Surg 2024; 280:640-649. [PMID: 38916098 PMCID: PMC11445716 DOI: 10.1097/sla.0000000000006414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
OBJECTIVE We sought to determine the premium associated with a career in academic surgery, as measured by compensation normalized to the work relative value unit (wRVU). BACKGROUND An academic surgical career embodying innovation and mentorship offers intrinsic rewards but is not well monetized. We know compensation for academic surgeons is less than their nonacademic counterparts, but the value of clinical effort, as normalized to the wRVU, between academic and nonacademic surgeons has not been well characterized. Thus, we analyzed the variations in the valuation of academic and nonacademic surgical work from 2010 to 2022. METHODS We utilized Medical Group Management Association Provider Compensation data from 2010, 2014, 2018, and 2022 to compare academic and nonacademic surgeons. We analyzed raw total cash compensation (TCC), wRVU, TCC per wRVU (TCC/wRVU), and TCC to collections (TCCtColl). We calculated collections per wRVU (Coll/wRVU). We adjusted TCC and TCCtColl for inflation using the Consumer Price Index. Linear modeling for trend analysis was performed. RESULTS Compared with nonacademic, academic surgeons had lower TCC (2010: $500,415.0±23,666 vs $631,515.5±23,948.2, -21%; 2022: $564,789.8±23,993.9 vs $628,247.4±15,753.2, -10%), despite higher wRVUs (2022: 9109.4±474.9 vs 8062.7±252.7) and higher Coll/wRVU (2022: 76.68±8.15 vs 71.80±6.10). Trend analysis indicated that TCC will converge in 2038 at an estimated $660,931. CONCLUSIONS In 2022, academic surgeons had more clinical activity and superior organizational revenue capture, despite less total and normalized clinical compensation. On the basis of TCC/wRVUs, academia charges a premium of 16% over nonacademic surgery. However, trend analysis suggests that TCC will converge within the next 20 years.
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Affiliation(s)
| | | | | | - Tyler Zander
- Department of Surgery, University of South Florida, Tampa, FL
| | - Rajavi Parikh
- Department of Surgery, University of South Florida, Tampa, FL
| | | | - Paul C. Kuo
- Department of Surgery, University of South Florida, Tampa, FL
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3
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Tsui GO, Kunac A, Oliver JB, Mehra S, Anjaria DJ. Did Residents Stop Operating During COVID? Impact of COVID-19 Across VA Teaching Hospitals on Surgical Resident Education. Am Surg 2024; 90:1015-1022. [PMID: 38059816 DOI: 10.1177/00031348231220598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
BACKGROUND During the COVID-19 pandemic, elective cases across the nation were suspended, leading to major decreases in operative volume for surgical trainees. Surgical resident operative autonomy has been declining over time, so we sought to explore the effect COVID-19 had on resident autonomy within VA teaching hospitals. METHODS A retrospective analysis of surgical cases across specialties was performed using the VA Surgical Quality Improvement Program database from September 2019 to September 2021 at VA teaching hospitals. Supervision codes are recorded prospectively: attending surgeon performs the operation (AP), resident completes majority of the case with the attending scrubbed (AR), and resident is primary surgeon without attending scrubbed (RP). RESULTS 20,457 cases pre-COVID decreased to 11,035 during peak-COVID (P < .001). Overall, RP cases increased from 6.5% to 7.6% during the peak (P < .001) and trended back downwards during the recovery periods. AP decreased initially (29.9%-27.7%, P < .001), but regressed back to pre-pandemic numbers. In general surgery RP cases, urgent cases such as laparoscopic cholecystectomies increased from 18.8% to 27.5%, while elective repairs decreased during the peak. Similar changes were noted across specialties. DISCUSSION Operative cases dropped by half from pre- to peak- COVID and remained 20% below pre-pandemic volume the following year. Interestingly, RP rates increased for several specialties during the peak of the pandemic, which may have resulted from a relative higher ratio of resident personnel:case volume and shift in case distribution from elective to urgent. The increase in RP rate has begun to regress to pre-COVID levels which need to be readdressed.
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Affiliation(s)
- Grace O Tsui
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ, USA
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Anastasia Kunac
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ, USA
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Joseph B Oliver
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ, USA
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Shyamin Mehra
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Devashish J Anjaria
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ, USA
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
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Robinson MA, Bowen JL, Aylor M, van Schaik S. Having a Voice: Resident Perceptions of Supervision, Decision-Making and Patient Care Ownership. Acad Pediatr 2024; 24:519-526. [PMID: 37951350 DOI: 10.1016/j.acap.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/18/2023] [Accepted: 10/26/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVE Heightened resident supervision due to patient safety concerns is increasingly common in pediatrics and may leave residents with fewer opportunities for independent decision-making, a diminished sense of autonomy, and decreased engagement. This may ultimately threaten their development into competent clinicians. Understanding how pediatric residents experience supervision's influence on their involvement in decision-making, engagement in patient care, and learning is crucial to safeguard their transition to independent practice. In relation to supervision, our research investigated: 1) how residents navigated their involvement with clinical decision-making and 2) how opportunities to make clinical decisions influenced their engagement in patient care and learning. METHODS From 2019-2020, we recruited 38 pediatric residents from three different programs for a qualitative interview-based study. Through a constructivist stance, we explored clinical decision-making experiences and performed thematic analysis using an iterative and inductive process. RESULTS We identified three themes: 1) Residents perceived having autonomy when they had space to make independent decisions, regardless of supervisor's presence; 2) Patient care ownership resulted from having a voice in a variety of contributions to patient care; and 3) Supervisors' behaviors modulated patient care ownership and thereby residents' sense of feeling heard, their engagement in patient care, and their learning. CONCLUSIONS Our results suggest that focusing on patient care ownership may better fit with current learning environments than aiming for independence and autonomy. They provide insight on how, in the pediatric learning climate of enhanced supervision, supervisors can preserve resident engagement in patient care and learning by augmenting patient care ownership and ensuring residents have a voice.
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Affiliation(s)
- Margaret A Robinson
- Division of Pediatric Critical Care Medicine (MA Robinson and S van Schaik), Department of Pediatrics, University of California, San Francisco, Calif.
| | - Judith L Bowen
- Elson S. Floyd College of Medicine (JL Bowen), Washington State University, Spokane, Wash
| | - Megan Aylor
- Department of Pediatrics (M Aylor), Oregon Health and Science University, Portland, Ore
| | - Sandrijn van Schaik
- Division of Pediatric Critical Care Medicine (MA Robinson and S van Schaik), Department of Pediatrics, University of California, San Francisco, Calif
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Kambakamba P, Naiem A, Betz E, Hotz AS, Richetti K, Stein M, Abry L, Meier A, Seeger N, Grochola F, Grieder F, Breitenstein S. Applying augmented reality in teaching of surgical residents-telementoring, a "stress-free" way to surgical autonomy? Langenbecks Arch Surg 2024; 409:100. [PMID: 38504065 DOI: 10.1007/s00423-024-03287-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 03/11/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Achieving surgical autonomy can be considered the ultimate goal of surgical training. Innovative head-mounted augmented reality (AR) devices enable visualization of the operating field and teaching from remote. Therefore, utilization of AR glasses may be a novel approach to achieve autonomy. The aim of this pilot study is to analyze the feasibility of AR application in surgical training and to assess its impact on intraoperative stress. METHODS A head-mounted RealWear Navigator® 500 glasses and the TeamViewer software were used. Initial "dry lab" testing of AR glasses was performed in combination with the Symbionix LAP Mentor™. Subsequently, residents performed various stage-adapted surgical procedures semi-autonomously (SA) (on-demand consultation of senior surgeon, who is in theatre but not scrubbed) versus permanent remote supervision (senior surgeon not present) via augmented reality (AR) glasses, worn by the resident in theatre. Stress was measured by intraoperative heart rate (Polar® pulse belt) and State-Trait Anxiety Inventory (STAI) questionnaire. RESULTS After "dry lab" testing, N = 5 senior residents performed equally N = 25 procedures SA and with AR glasses. For both, open and laparoscopic procedure AR remote assistance showed satisfactory applicability. Utilization of AR significantly reduced intraoperative peak pulse rate from 131 to 119 bpm (p = 0.004), as compared with the semi-autonomous group. Likewise, subjectively perceived stress according to STAI was significantly lower in the AR group (p = 0.011). CONCLUSION AR can be applied in surgical training and may help to reduce stress in theatre. In the future, AR has a huge potential to become a stepping stone to surgical autonomy.
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Affiliation(s)
- Patryk Kambakamba
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.
| | - Amir Naiem
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Elise Betz
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Anne-Sophie Hotz
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Katharina Richetti
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Moritz Stein
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Lisa Abry
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Aline Meier
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Nico Seeger
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Filip Grochola
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Felix Grieder
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Stefan Breitenstein
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
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Tsui GO, Kunac A, Oliver JB, Mehra S, Anjaria DJ. Why Not This Case? Differences Between Resident and Attending Operative Cases at Teaching Hospitals. J Surg Res 2024; 295:19-27. [PMID: 37972437 DOI: 10.1016/j.jss.2023.09.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 09/13/2023] [Accepted: 09/25/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Previous studies have focused on outcomes pertaining to resident operative autonomy, but there has been little academic work examining the types of patients and cases where autonomy is afforded. We sought to describe the differences between surgical patient populations in teaching cases where residents are and are not afforded autonomy. METHODS We examined all general and vascular operations at Veterans Affairs teaching hospitals from 2004 to 2019 using Veterans Affairs Surgical Quality Improvement Program. Level of resident supervision is prospectively recorded by the operating room nurse at the time of surgery: attending primary (AP): the attending performs the case with or without a resident; attending resident (AR): the resident performs the case with the attending scrubbed; resident primary (RP): resident operating with supervising attending not scrubbed. Resident (R) cases refer to AR + RP. Patient demographics, comorbidities, level of supervision, and top cases within each group were evaluated. RESULTS A total of 618,578 cases were analyzed; 154,217 (24.9%) were AP, 425,933 (68.9%) AR, and 38,428 (6.2%) RP. Using work relative value unit as a surrogate for complexity, RP was the least complex compared to AP and AR (10.4/14.4/14.8, P < 0.001). RP also had a lower proportion of American Society of Anesthesiologists 3 and 4 + 5 patients (P < 0.001), were younger (P < 0.001), and generally had lower comorbidities. The most common RP cases made up a higher proportion of all RP cases than they did for AP/AR and demonstrated several core competencies (hernia, cholecystectomy, appendectomy, amputation). R cases, however, were generally sicker than AP cases. CONCLUSIONS In the small proportion of cases where residents were afforded autonomy, we found they were more focused on the core general surgery cases on lower risk patients. This selection bias likely demonstrates appropriate attending judgment in affording autonomy. However, this cohort consisted of many "sicker" patients and those factors alone should not disqualify resident involvement.
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Affiliation(s)
- Grace O Tsui
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Anastasia Kunac
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Joseph B Oliver
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Shyamin Mehra
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Devashish J Anjaria
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
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Schwed AC, Chen KT, de Virgilio CM. Preserving and Enhancing Resident Autonomy-Strategies for Surgical Educators. JAMA Surg 2024; 159:9-10. [PMID: 37851454 DOI: 10.1001/jamasurg.2023.3819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
This Viewpoint suggests measures to improve surgical resident autonomy and thereby produce capable and resilient surgeons.
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Affiliation(s)
| | - Kathryn T Chen
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
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8
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Thelen AE, Marcotte KM, Diaz S, Gates R, Chen X, George BC, Krumm AE. Variation in Competence of Graduating General Surgery Trainees. JOURNAL OF SURGICAL EDUCATION 2024; 81:17-24. [PMID: 38036389 DOI: 10.1016/j.jsurg.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 07/22/2023] [Accepted: 11/03/2023] [Indexed: 12/02/2023]
Abstract
OBJECTIVE To examine the readiness of general surgery residents in their final year of training to perform 5 common surgical procedures based on their documented performance during training. DESIGN Intraoperative performance ratings were analyzed using a Bayesian mixed effects approach, adjusting for rater, trainee, procedure, case complexity, and postgraduate year (PGY) as random effects as well as month in academic year and cumulative, procedure-specific performance per trainee as fixed effects. This model was then used to estimate each PGY 5 trainee's final probability of being able to independently perform each procedure. The actual, documented competency rates for individual trainees were then identified across each of the 5 most common general surgery procedures: appendectomy, cholecystectomy, ventral hernia repair, groin hernia repair, and partial colectomy. SETTING This study was conducted using data from members of the SIMPL collaborative. PARTICIPANTS A total of 17,248 evaluations of 927 PGY5 general surgery residents were analyzed from 2015 to 2021. RESULTS The percentage of residents who requested a SIMPL rating during their PGY5 year and achieved a ≥90% probability of being rated as independent, or "Practice-Ready," was 97.4% for appendectomy, 82.4% for cholecystectomy, 43.5% for ventral hernia repair, 24% for groin hernia repair, and 5.3% for partial colectomy. CONCLUSIONS There is substantial variation in the demonstrated competency of general surgery residents to perform several common surgical procedures at the end of their training. This variation in readiness calls for careful study of how surgical residents can become more adequately prepared to enter independent practice.
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Affiliation(s)
- Angela E Thelen
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, Michigan; MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Kayla M Marcotte
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, Michigan; University of Michigan Medical School, Ann Arbor, Michigan; Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan
| | - Sarah Diaz
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, Michigan; University of Michigan Medical School, Ann Arbor, Michigan
| | - Rebecca Gates
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Xilin Chen
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Brian C George
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew E Krumm
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan
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Yu Y, Oliver JB, Kunac A, Sehat AJ, Anjaria DJ. Declining Surgical Resident Operative Autonomy-All Trainees Are Not Created Equal. J Surg Res 2023; 292:330-338. [PMID: 37117092 DOI: 10.1016/j.jss.2023.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 02/07/2023] [Accepted: 02/18/2023] [Indexed: 04/30/2023]
Abstract
INTRODUCTION We have previously shown that resident autonomy has decreased over time overall for all surgery residents. The purpose of this study is to examine changes in operative autonomy in general surgery residency within each postgraduate year (PGY) level. MATERIALS AND METHODS This is a retrospective analysis of the Veterans Association Surgical Quality Improvement Program database from July 1, 2004 to September 30, 2019. All general surgery, vascular surgery, and thoracic surgery procedures were analyzed and categorized by level of resident supervision as attending primary, attending operating with resident, or resident primary without attending scrubbed. Procedure work portion of relative value unit was used to capture procedure complexity. Changes in resident autonomy over time, procedure complexity, and outcomes were compared among PGY levels 1 to 5. RESULTS A total of 385,482 cases were analyzed. At each PGY level from 2014 to 2018, the relative decrease in resident primary cases ranged from -37.3% (PGY 4) to -75.5% (PGY 3). Mean work portion of relative value unit saw steady increase with PGY level (8.4 ± 3.5 in PGY 1 to 10.8 ± 5.7 in PGY 5, P < 0.001) and did not show a trend over time. CONCLUSIONS Surgical resident operative autonomy has markedly decreased over time across all PGY levels. This effect is most profound at the PGY 3 level, while more senior residents are affected to a lesser degree. Case complexity show PGY level-appropriate increase in resident autonomous cases. Decrease in resident autonomy over time is not associated with changes in case complexity.
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Affiliation(s)
- Yasong Yu
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Joseph B Oliver
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Anastasia Kunac
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Alvand J Sehat
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey
| | - Devashish J Anjaria
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
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10
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Mehra S, Oliver JB, Kunac A, Tsui GO, Anjaria DJ. Cross-Specialty Training: An Opportunity to Expand the General Surgery Resident's Operative Repertoire. Curr Probl Surg 2023; 60:101380. [PMID: 37993240 DOI: 10.1016/j.cpsurg.2023.101380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Shyamin Mehra
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ; Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Joseph B Oliver
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ; Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Anastasia Kunac
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ; Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Grace O Tsui
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ; Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Devashish J Anjaria
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ; Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.
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11
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Suarez A, Haglund MM, Selden NR, Selman W. Letter: Neurosurgical Educators. Neurosurgery 2023; 93:e102-e104. [PMID: 37466322 DOI: 10.1227/neu.0000000000002616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 07/20/2023] Open
Affiliation(s)
- Alexander Suarez
- Department of Neurosurgery, Duke University School of Medicine, Durham , North Carolina , USA
| | - Michael M Haglund
- Department of Neurosurgery, Duke University School of Medicine, Durham , North Carolina , USA
| | - Nathan R Selden
- Department of Neurological Surgery, Oregon Health & Science University, Portland , Oregon , USA
| | - Warren Selman
- Department of Neurosurgery, University Hospitals Cleveland and Case Western Reserve University, Cleveland , Ohio , USA
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Parker RK, Otoki K, Sylvester K, Roberts L, Many HR, Kim GJ, Mwachiro MM, Parker AS. Trainee autonomy and surgical outcomes after emergency gastrointestinal surgery. Surgery 2023; 174:324-329. [PMID: 37263881 DOI: 10.1016/j.surg.2023.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/25/2023] [Accepted: 04/27/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Operative meaningful trainee autonomy is an essential component of surgical training. Reduced trainee autonomy is frequently attributed to patient safety concerns, but this has not been examined within Kenya. We aimed to assess whether meaningful trainee autonomy was associated with a change in patient outcomes. METHODS We investigated whether meaningful trainee autonomy was associated with a change in severe postoperative complications and all-cause in-hospital mortality in a previously described cohort undergoing emergency gastrointestinal operations. Each operation was reviewed to determine the presence of meaningful autonomy, defined as "supervision only" from faculty. Comparisons were made between faculty-led cases and cases with meaningful trainee autonomy. Multilevel logistic regression models were created for the outcomes of mortality and complications with the exposure of meaningful trainee autonomy, accounting for fixed effects of the Africa Surgical Outcomes Study Risk Score and random effects of discharge diagnoses. RESULTS After excluding laparoscopy (N = 28) and missing data (N = 3), 451 operations were studied, and 343 (76.1%) had meaningful trainee autonomy. Faculty were more involved in operations with older age, cancer, prior complications, and higher risk scores. On unadjusted analysis, meaningful trainee autonomy was associated with mortality odds of 0.32 (95% confidence interval: 0.17-0.58) compared with faculty-led operations. Similarly, the odds of developing complications were 0.52 (95% confidence interval: 0.32-0.84) with meaningful trainee autonomy compared with faculty-led operations. When adjusting for Africa Surgical Outcomes Study Score and clustering discharge diagnoses, the odds of mortality (odds ratio 0.58; 95% confidence interval: 0.27-1.2) and complication (odds ratio 0.83; 95% confidence interval: 0.47-1.5) were not significant. CONCLUSION Our findings support that increasing trainee autonomy does not change patient outcomes in selected emergency gastrointestinal operations. Further, trainees and faculty appropriately discern patients at higher risk of complications and mortality, and the selective granting of trainee autonomy does not affect patient safety.
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Affiliation(s)
| | - Kemunto Otoki
- Department of Surgery, Tenwek Hospital, Bomet, Kenya. https://twitter.com/kemuntootoki
| | | | - Luke Roberts
- Department of Surgery, Tenwek Hospital, Bomet, Kenya
| | - Heath R Many
- Department of Surgery, University of Tennessee Medical Center, Knoxville, TN
| | - Grace J Kim
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, MI. https://twitter.com/3amazinggrace
| | - Michael M Mwachiro
- Department of Surgery, Tenwek Hospital, Bomet, Kenya. https://twitter.com/MichaelMwachiro
| | - Andrea S Parker
- Department of Surgery, Tenwek Hospital, Bomet, Kenya. https://twitter.com/AP_the_surgeon
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Nguyen AT, Anjaria DJ, Sadeghi-Nejad H. Advancing Urology Resident Surgical Autonomy. Curr Urol Rep 2023; 24:253-260. [PMID: 36917339 PMCID: PMC10011787 DOI: 10.1007/s11934-023-01152-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 03/16/2023]
Abstract
PURPOSE OF REVIEW This paper aims to survey current literature on urologic graduate medical education focusing on surgical autonomy. RECENT FINDINGS Affording appropriate levels of surgical autonomy has a key role in the education of urologic trainees and perceived preparedness for independent practice. Recent studies in surgical resident autonomy have demonstrated a reduction in autonomy for trainees in recent years. Efforts to advance the state of modern surgical training include creation of targeted curricula, enhanced with use of surgical simulation, and structured feedback. Decline in surgical autonomy for urology residents may influence confidence after completion of their residency. Further study is needed into the declining levels of urology resident autonomy, how it affects urologists entering independent practice, and what interventions can advance autonomy in modern urologic training.
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Affiliation(s)
- Anh T Nguyen
- Division of Urology Rutgers New Jersey Medical School, Newark, NJ, 07103, USA.
| | - Devashish J Anjaria
- East Orange Department of Surgery, Veteran Affairs New Jersey Healthcare System East Orange, East Orange, NJ, USA
| | - Hossein Sadeghi-Nejad
- East Orange Department of Surgery, Veteran Affairs New Jersey Healthcare System East Orange, East Orange, NJ, USA
- Hackensack University Medical Center, Hackensack, NJ, USA
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Beck T, Burneikis T, Jin J. Parathyroidectomy trends and surgical trainee parathyroidectomy experience based on the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) database. Am J Otolaryngol 2023; 44:103884. [PMID: 37058910 DOI: 10.1016/j.amjoto.2023.103884] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/01/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND The parathyroidectomy approach has shifted over the last few decades from routine bilateral to more commonly focused exploration. The purpose of this study is to assess the operative experience in parathyroidectomy for surgical trainees as well as overall parathyroidectomy trends. METHODS Data from the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) were analyzed between 2014 and 2019. RESULTS The overall distribution of focused versus bilateral parathyroidectomy remained stable (2014: 54 % focused and 46 % bilateral approach; 2019: 55 % focused and 45 % bilateral). Ninety three percent of procedures involved a trainee (fellow or resident) in 2014, this dropped to 74 % in 2019 (P < 0.005). Fellow involvement decreased significantly from 31 % to 17 % (P < 0.05) over the six-year period. CONCLUSIONS Resident exposure to parathyroidectomies mirrored that of practicing endocrine surgeons. This works highlights the opportunities to capture more information regarding the surgical trainee experience in endocrine surgeries.
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Portuondo JI, Whitlock RS, Mehl SC, Massarweh NN. Variation in Resident Operative Autonomy at Veterans Affairs Hospitals. JAMA Surg 2023; 158:321-323. [PMID: 36576814 PMCID: PMC9857278 DOI: 10.1001/jamasurg.2022.4791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/14/2022] [Indexed: 12/29/2022]
Abstract
This cohort study examines resident involvement in the care of US veterans who underwent noncardiac surgery.
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Affiliation(s)
- Jorge I. Portuondo
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Richard S. Whitlock
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Steven C. Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Pediatric Surgery, Texas Children’s Hospital, Houston
| | - Nader N. Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
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Oliver JB, McFarlane JL, Kunac A, Anjaria DJ. Declining Resident Surgical Autonomy and Improving Surgical Outcomes: Correlation Does Not Equal Causality. JOURNAL OF SURGICAL EDUCATION 2023; 80:434-441. [PMID: 36335032 DOI: 10.1016/j.jsurg.2022.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/06/2022] [Accepted: 10/16/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The volume of cases that residents perform independently have decreased leaving graduating chief residents less prepared for independent practice. Outcomes are not worse when residents are given autonomy with appropriate supervision, however it is unknown if outcomes are worsening with decreasing operative autonomy experience. We hypothesize that resident autonomous cases parallel the improving outcomes in surgical care over time, however, are less complex and on lower acuity patients. DESIGN Retrospective study utilizing the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. SETTING Operative cases performed on teaching services within the VASQIP database from July 1, 2004 to September 30, 2019, were included. PARTICIPANTS All adult patients who underwent a surgical procedure from July 1, 2004, to September 30, 2019, at a VA hospital on a service that included residents were initially included. After inclusions and exclusions, there were 1,346,461 cases. Cases were divided into 3 sequential 5 year eras (ERA 1: 2004-2008 n = 415,614, ERA 2: 2009-2013 n = 478,528, and ERA 3: 2014-2019 n = 452,319). The main exposure of interest was level of resident supervision, coded at the time of procedure as: attending primary surgeon (AP); attending and resident (AR), or resident primary with the attending supervising but not scrubbed (RP). We compared 30 day all-cause mortality, composite morbidity, work relative value unit (wRVU), hospital length of stay, and operative time between each ERA for RP cases, as well as within each ERA for RP cases compared to AR and AP cases. RESULTS There was a progressive decline in the rate of RP cases in each successive ERA (ERA 1: 58,249 (14.0%) vs ERA 2: 47,891 (10.0%) vs ERA 3: 35,352 (7.8%), p < 0.001). For RP cases, patients were progressively getting older (60 yrs [53-71] vs 63 yrs [54-69] vs 66 yrs [57-72], p < 0.001) and sicker (ASA 3 58.7% vs 62.5% vs 66.2% and ASA 4/5 8.4% vs 9.6% vs10.0%, p < 0.001). Odds of mortality decreased in each ERA compared to the previous (aOR 0.71 [0.62-0.80] ERA 2 vs ERA 1 and 0.82 [0.70-0.97] ERA 3 vs ERA 2) as did morbidity (0.77 [0.73-0.82] ERA 2 vs ERA 1 and 0.72 [0.68-0.77] ERA 3 vs ERA 2). Operative and length of stay also decreased while wRVU stayed unchanged. When comparing RP cases to AP and AR within each ERA, RP cases tended to be on younger and healthier patients with a lower wRVU, particularly compared to AR cases. Mortality and morbidity were no different or better in RP compared to AR and AP. CONCLUSIONS Despite resident autonomy decreasing, outcomes in cases where they are afforded autonomy are improving over time. This despite RP cases being on sicker and older patients and performing roughly the same complexity of cases. They also continue to perform no worse than cases with higher levels of supervision. Efforts to increase surgical resident operative autonomy are still needed to improve readiness for independent practice.
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Affiliation(s)
- Joseph B Oliver
- VA New Jersey Healthcare System, Department of Surgery, East Orange, New Jersey; Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey.
| | - Jamal L McFarlane
- VA New Jersey Healthcare System, Department of Surgery, East Orange, New Jersey; Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey
| | - Anastasia Kunac
- VA New Jersey Healthcare System, Department of Surgery, East Orange, New Jersey; Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey
| | - Devashish J Anjaria
- VA New Jersey Healthcare System, Department of Surgery, East Orange, New Jersey; Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey
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Sehat AJ, Oliver JB, Yu Y, Kunac A, Anjaria DJ. Declining Surgical Resident Operative Autonomy in Acute Care Surgical Cases. J Surg Res 2023; 281:328-334. [PMID: 36240719 DOI: 10.1016/j.jss.2022.08.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/06/2022] [Accepted: 08/20/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Surgical resident operative autonomy has decreased markedly over time, reducing resident readiness for independent practice. We sought to examine operative resident autonomy for emergency acute care surgery (ACS) compared to elective cases and associated patient outcomes at veterans affairs hospitals. METHODS The Veterans Affairs Surgical Quality Improvement Program database was queried for ACS cases (emergency general, vascular, and thoracic) at veterans affairs hospitals from 2004 to 2019. Cases are coded prospectively for the level of supervision: attending primary surgeon (AP); attending scrubbed with resident surgeon (AR); resident primary (RP), attending not scrubbed. Baseline demographics, operative variables, and outcomes were compared. RESULTS A total of 61,275 ACS cases and 605,146 elective cases were performed during the study period. The ACS had a higher proportion of RP cases (7.2% versus 5.7%, P < 0.001). The proportion of ACS RP cases decreased from 9.9% to 4.1% (58.6%); elective RP cases decreased from 8.9% to 2.9% (67.4%). The most common ACS RP surgeries were appendectomy, amputations, and cholecystectomy. RP cases had lower American Society of Anesthesia class and lower median work relative value units than AP and AR. There was no difference between mortality rates of RP compared to AP (adjusted odds ratio [OR] 0.94 [0.80-1.09] or AR 0.94 [0.81-1.08]). While there was no difference in complications between the RP and AP (OR 1.01 [0.92-1.12]), there were significantly more complications in AR compared to RP (OR 1.20 [1.10-1.31]). CONCLUSIONS More autonomy is granted for ACS cases compared to elective cases. While both decreased over time, the decrease is less for ACS cases. Resident autonomy does not negatively impact outcomes, even in emergent cases.
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Affiliation(s)
- Alvand J Sehat
- Department of Surgery, Rutgers Health New Jersey Medical School, Newark, New Jersey
| | - Joseph B Oliver
- Department of Surgery, Rutgers Health New Jersey Medical School, Newark, New Jersey; Department of Surgery, Veterans Administration, New Jersey Health Care System, East Orange, New Jersey
| | - Yasong Yu
- Department of Surgery, Rutgers Health New Jersey Medical School, Newark, New Jersey; Department of Surgery, Veterans Administration, New Jersey Health Care System, East Orange, New Jersey
| | - Anastasia Kunac
- Department of Surgery, Rutgers Health New Jersey Medical School, Newark, New Jersey; Department of Surgery, Veterans Administration, New Jersey Health Care System, East Orange, New Jersey
| | - Devashish J Anjaria
- Department of Surgery, Rutgers Health New Jersey Medical School, Newark, New Jersey; Department of Surgery, Veterans Administration, New Jersey Health Care System, East Orange, New Jersey.
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Tsui GO, Duncan G, Yu Y, Oliver JB, Anjaria DJ, Kunac A. Patient inequities in affording surgical resident operative autonomy at Veterans Affairs teaching hospitals, does it extend to female patients? Am J Surg 2023; 225:40-45. [PMID: 36192216 DOI: 10.1016/j.amjsurg.2022.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/14/2022] [Accepted: 09/18/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Examining surgical resident operative autonomy within the Veterans Affairs (VA) System, we previously showed residents were afforded autonomy more frequently on Black patients. We hypothesized that, compared to males, female surgical patients receive less attending involvement and more resident autonomy during surgery. METHODS Retrospective review of all general/vascular surgeries performed at teaching VA hospitals from 2004 to 2019. Operative procedures are coded at the time of surgery as attending primary surgeon (AP), attending with resident (AR), or resident primary surgeon--attending not scrubbed (RP). The primary outcome was the difference in supervision rates between patient sexes. RESULTS 618,578 operations were examined-24.9% AP, 68.9% AR, and 6.2% RP. Overall, 5.9% of cases were performed on women. The rate of RP cases was higher in males compared to females (6.3% vs 5.3%, p < 0.001). CONCLUSION Female veterans are less likely to have residents operate on them autonomously. Reasons for this require further characterization.
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Affiliation(s)
- Grace O Tsui
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ, 07018, USA
| | - Gianna Duncan
- American University of the Caribbean School of Medicine, St. Maarten, the Netherlands
| | - Yasong Yu
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ, 07018, USA; Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, 07103, USA
| | - Joseph B Oliver
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ, 07018, USA; Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, 07103, USA
| | - Devashish J Anjaria
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ, 07018, USA; Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, 07103, USA
| | - Anastasia Kunac
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ, 07018, USA; Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, 07103, USA.
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Yu Y, Kunac A, Oliver JB, Sehat AJ, Anjaria DJ. General Surgery Resident Complement and Operative Autonomy - Size Matters. JOURNAL OF SURGICAL EDUCATION 2022; 79:e76-e84. [PMID: 36253329 DOI: 10.1016/j.jsurg.2022.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/21/2022] [Accepted: 09/11/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Operative autonomy has progressively decreased for surgery residents. This study investigates the effect of general surgery resident complement size at Veterans Affairs (VA) hospitals on operative autonomy for the residents. We hypothesize that smaller complements of residents would result in fewer opportunities for operative autonomy. DESIGN Retrospective analysis of the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. SETTING Operative cases within the VASQIP database from July 1, 2004 to September 30, 2019 were analyzed. PARTICIPANTS All general surgery procedures performed at teaching VA hospitals from January 2004 to September 2019 were included. The level of resident operative autonomy is defined as follows: attending primary surgeon with or without a resident (AP), resident primary surgeon with attending scrubbed (AR), and resident primary without attending scrubbed (RP). Resident complement is based on funded resident positions at each VA hospital during the academic year 2017-2018 and stratified into 3 groups: small (≤4), medium (>4-<7), and large (≥7). The primary outcome was the proportion of operative autonomy for each resident complement group. Secondary outcomes were level of autonomy over time, and mortality and morbidity for RP procedures. Categorical data were compared with Chi-squared test. RESULTS Four hundred sixty-one thousand seven hundred thirty-four procedures across 92 VA hospitals with general surgery residents were included in the analysis. There were 126,062 cases performed at 29 small resident complement hospitals, 135,539 at 28 medium resident complement hospitals, and 200,133 at 35 large resident complement hospitals. The percentage of RP procedures was higher with increasing resident complement (2.1% vs 6.8% vs 9.9%, p < 0.001). RP procedures have decreased over time in all groups, but the relative decrease was less pronounced as resident complement increased (79.5% vs 73.3% vs 64.7%, p < 0.001). There was no significant difference in adjusted 30-day all-cause mortality between groups. CONCLUSIONS Increased resident complement at VA hospitals is associated with increased resident autonomy in resident primary procedures. Resident autonomy has decreased over time regardless of complement size, but it is less dramatic at sites with more residents. Increasing resident complement at a site may improve operative autonomy, leading to an improved educational experience for surgical residents.
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Affiliation(s)
- Yasong Yu
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Anastasia Kunac
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Joseph B Oliver
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Alvand J Sehat
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Devashish J Anjaria
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
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Sehat AJ, Oliver JB, Yu Y, Kunac A, Anjaria DJ. Increasing volume but declining resident autonomy in laparoscopic inguinal hernia repair: an inverse relationship. Surg Endosc 2022; 37:3119-3126. [PMID: 35931892 DOI: 10.1007/s00464-022-09476-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/13/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION With improved technology and technique, laparoscopic inguinal hernia repair (LIHR) has become a valid option for repairing both initial and recurrent inguinal hernia. Surgical residents must learn both techniques to prepare for future practice. We examined resident operative autonomy between LIHR and open inguinal hernia repair (OIHR) across the Veterans Affairs (VA) system. METHODS Utilizing the VA Surgical Quality Improvement Program database, we examined inguinal hernia repairs based on the principal procedure code at all teaching VA hospitals from July 2004 to September 2019. All VA cases are coded for level of supervision at the time of surgery: attending primary surgeon (AP); attending scrubbed but resident is a primary surgeon (AR), and resident primary with attending supervising but not scrubbed (RP). Primary outcomes were the proportion of LIHR versus OIHR and resident autonomy over time. RESULTS A total of 127,497 hernia repair cases were examined (106,892 OIHR and 20,605 LIHR). There was a higher proportion of RP (8.7% vs 2.2%) and lower proportion of AP (23.9% vs 28.4%) within OIHR compared to LIHR (p < 0.001). The overall proportion of LIHR repairs increased from 9 to 28% (p < 0.001). RP cases decreased for LIHR from 9 to 1% and for OIHR from 17 to 4%, while AP cases increased for LIHR from 16 to 42% and for OIHR from 18 to 30% (all p < 0.001). For RP cases, mortality (0 vs 0.2%, p > 0.99) and complication rates (1.1% vs. 1.7%, p = 0.35) were no different. CONCLUSIONS LIHR at VA hospitals has tripled over the past 15 years, now compromising nearly one-third of all inguinal hernia repairs; the majority are initial hernias. Despite this increase, resident autonomy in LIHR cases declined alarmingly. The results demonstrate an urgent need to integrate enhanced minimally invasive training into a general surgery curriculum to prepare residents for future independent practice.
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Affiliation(s)
- Alvand J Sehat
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, US
| | - Joseph B Oliver
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, US.,Department of Surgery, VA New Jersey Health Care System, 385 Tremont Ave, East Orange, New Jersey, US
| | - Yasong Yu
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, US.,Department of Surgery, VA New Jersey Health Care System, 385 Tremont Ave, East Orange, New Jersey, US
| | - Anastasia Kunac
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, US.,Department of Surgery, VA New Jersey Health Care System, 385 Tremont Ave, East Orange, New Jersey, US
| | - Devashish J Anjaria
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, US. .,Department of Surgery, VA New Jersey Health Care System, 385 Tremont Ave, East Orange, New Jersey, US.
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Schumm MA, Huang IA, Blair KJ, Nameth C, Tseng CH, Quach C, Wagner JP, Lewis CE, Donahue TR, Tillou A. Association of research timing with surgery resident perceptions of operative autonomy and satisfaction: A multi-institutional study. Surgery 2022; 172:102-109. [DOI: 10.1016/j.surg.2022.01.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 01/15/2022] [Accepted: 01/31/2022] [Indexed: 10/18/2022]
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