Surgical Training in the United States: Is It Time for a Paradigm Shift?

A retrospective observational study of patient analgesia outcomes when regional anaesthesia procedures are performed by consultants versus supervised trainees

At teaching hospitals, consultants must provide effective supervision, including appropriate selection of teaching cases, such that the outcomes achieved by trainees are similar to that of consultants. Numerous studies in the surgical literature have compared patient outcomes when surgery is performed by consultant surgeons or surgical trainees but, to our knowledge, none exist in the field of anaesthesia. We aimed to compare analgesia outcomes of regional anaesthesia when performed by supervised trainees versus consultants. We designed a retrospective observational study using registry data. The primary outcome was inadequate analgesia, defined as a numerical rating scale (NRS) for pain >5 reported at any time in the post-anaesthesia care unit (PACU). Secondary outcomes included the maximum pain NRS, pain experienced in the PACU, and the requirement for systemic opioid analgesia in the PACU. Of the 1814 patients analysed, the primary proceduralist was a consultant for 514 (28.3%) patients and a trainee for 1300 (71.7%) patients. All trainees were supervised by an on-site consultant. There were no statistically significant differences between consultants and supervised trainees in terms of the primary outcome (NRS >5 in 24.9% and 24.5% of patients, respectively; P = 0.84) and secondary outcomes. Compared to trainees, consultants had a slightly higher rate of patients with a body mass index >30 kg/m², an American Society of Anesthesiologists Physical Status Classification of 3 or 4, nerve blocks performed under general anaesthesia, paravertebral/neuraxial blocks and blocks with perineural catheter placement. Regional anaesthesia performed by supervised trainees can achieve similar analgesia outcomes to consultant-performed procedures.

Building a Framework for Self-Regulated Learning in Surgical Education: A Delphi Consensus Among Experts in Surgical Education

OBJECTIVE

Practice-Based Learning and Improvement is a Core Competency for surgical residents. Self-regulated learning (SRL) skills are an important component of this competency, yet are rarely taught in surgical training. Before we can teach SRL skills to residents we must understand the attributes that are essential. The purpose of this study was to develop a framework for SRL for surgical trainees.

DESIGN

This mixed-methods study design utilized a two-round modified-Delphi approach to develop consensus among experts in surgical education regarding SRL in surgical training. Round One included SRL constructs derived from educational, professional, and medical literature. Based upon quantitative data and thematic coding of comments, these constructs were adapted for applicability in the context of surgical residency and reorganized using a constant comparative approach. Revised constructs and groupings were presented to the expert panel in Round Two. Further survey rounds were not needed as all items in Round Two reached the predetermined consensus level of 70%.

SETTING

The Delphi panel was a purposeful sample of nationally recognized experts in surgical education, including members of the Association for Surgical Education and the Association for Program Directors in Surgery.

PARTICIPANTS

Thirty-eight of 42 experts (90.5%) responded to Round One, representing 29 academic and community medical systems nationally. The response rate for Round Two was 92%, 35 of the 38 Round One participants.

RESULTS

In Round One, the SRL constructs were all viewed as important with median scores ranging from 50 to 99.5, on a 100-point scale. Two hundred and ninety-one comments were coded and used to refine SRL definitions into 7 domains for Round Two, which included self-awareness, task analysis, situation awareness, strategic planning, progress evaluation, learning and performance management, and goal attainment and refinement. All Round Two items reached greater than 70% agreement, and received 51 free response comments. Several key themes emerged: clinical prioritization over learning, learner's limited control, value and reliance on external resources, low use of metacognition, and complex goal orientation. Incorporation of common themes generated a novel multi-stage framework of SRL in surgical education.

CONCLUSIONS

Surgical residency represents a unique learning context, in which the ideal learner is one who understands their learning environment and utilizes available resources to optimize their own learning. Experts in surgical education believe SRL skills are important in training, and a novel framework of SRL is necessary to support a learner-centered model within the demanding environment of surgical training.

Impact of Trainee Involvement on Complication Rates Following Pelvic Reconstructive Surgery

OBJECTIVE

Trainee involvement in surgical procedures has been associated with longer surgical times and increased rates of certain complications. There has been limited study of the impact trainee involvement has on outcomes in urogynecologic surgery. We sought to determine the impact of resident and fellow involvement in pelvic reconstructive surgeries on 30-day complication rates.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, patients who underwent pelvic floor surgery were identified between 2010 and 2015. Patients were stratified into 3 groups: no trainee, resident, or fellow involvement. The primary outcome was the composite complication rate. Three-group comparison was performed using Kruskal-Wallis analysis. If statistically significant, then pairwise analysis was performed between the reference group (attending alone) and experimental groups (resident or fellow). Additional pairwise analysis was performed between the fellow and resident groups. Logistic regression was used to identify factors associated with an increased risk of complications.

RESULTS

Seven thousand seven hundred fifty-two surgical cases met all criteria for inclusion; 2440 (31.4%) included residents, and 646 (8.3%) included fellows. The median operating times were significantly higher in the resident and fellow groups compared with the attending-alone group (109 minutes [interquartile range, 55-164 minutes) compared with 110 minutes [interquartile range, 61-174 minutes] compared with 72 minutes [interquartile range, 38-113 minutes], P < 0.001). After multivariable logistic regression, trainee participation did not result in an increase in complication rate. Preoperative transfusion (adjusted odds ratio [aOR], 7.82; 95% confidence interval [CI], 2.03-30.09), coagulopathy (aOR, 3.18; 95% CI, 1.74-5.82), nonwhite race (aOR, 1.57; 95% CI, 1.31-1.89), insulin-dependent diabetes (aOR, 1.68; 95% CI, 1.03-2.72), American Society of Anesthesiologists class greater than 2 (aOR, 1.46; 95% CI, 1.21-1.77), length of stay (aOR, 1.04, 95%CI:1.02-1.06), operating time (aOR, 1.01; 95% CI, 1.00-1.03), and undergoing a sling procedure (aOR, 1.18; 95% CI, 1.01-1.41) were associated with higher complication rates.

CONCLUSIONS

Resident and fellow involvement during pelvic reconstructive surgery is associated with longer operating times but does not increase the risk of complications within 30 days of the procedure.