Public Perception of General Surgery Resident Autonomy and Supervision

Machine Learning Analysis of Postlaparoscopy Hernias and "I'm Leaving You to Close" Strategy

INTRODUCTION

Contributing factors to postlaparoscopy hernia are unknown. We hypothesized that postlaparoscopy incisional hernias are increased when the index surgery was performed in teaching hospitals. Laparoscopic cholecystectomy was chosen as the archetype for open umbilical access.

MATERIALS AND METHODS

Maryland and Florida SID/SASD databases (2016-2019) wereused to track 1-year hernia incidence in both inpatient and outpatient settings, which was then linked to Hospital Compare, Distressed Communities Index (DCI), and ACGME. Postoperative umbilical/incisional hernia following laparoscopic cholecystectomy was identified using CPT and ICD-10. Propensity matching and eight machine learning modes were utilized including logistic regression, neural network, gradient boosting machine, random forest, gradient boosted trees, classification and regression trees, k nearest neighbors and support vector machines.

RESULTS

Postoperative hernia incidence was 0.2% (total = 286; 261 incisional and 25 umbilical) in 117,570 laparoscopic cholecystectomy cases. Days to presentation (mean ± SD) were incisional 141 ± 92 and umbilical 66 ± 74. Logistic regression performed best (AUC 0.75 (95% ci 0.67-0.82) and accuracy 0.68 (95% ci 0.60-0.75) using 10-fold cross validation) in propensity matched groups (1:1; n = 279). Postoperative malnutrition (OR 3.5), hospital DCI of comfortable, mid-tier, at risk or distressed (OR 2.2 to 3.5), LOS >1 d (OR 2.2), postop asthma (OR 2.1), hospital mortality below national average (OR 2.0) and emergency admission (OR 1.7) were associated with increased hernias. A decreased incidence was associated with patient location of small metropolitan areas with <1 million residents (OR 0.5) and Charlson Comorbidity Index-Severe (OR 0.5). Teaching hospitals were not associated with postoperative hernia after laparoscopic cholecystectomy.

CONCLUSIONS

Different patient factors as well as underlying hospital factors are associated with postlaparoscopy hernias. Performance of laparoscopic cholecystectomy at teaching hospitals is not associated with increased postoperative hernias.

Advancing Urology Resident Surgical Autonomy

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.

Patient inequities in affording surgical resident operative autonomy at Veterans Affairs teaching hospitals, does it extend to female patients?

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.

Systematic review and meta-analysis comparing perioperative outcomes of pediatric emergency appendicectomy performed by trainee vs trained surgeon

Appendicectomy is a common pediatric surgical procedure performed by trainees and surgeons with varying reported outcomes. It is a benchmark procedure for trainee progression and training benefits should be weighed against patient safety and perioperative outcomes. This systematic review and meta-analysis investigated any differential perioperative outcomes dependent on the grade of the operating surgeon. A systematic literature review and meta-analysis were performed comparing outcomes of pediatric appendicectomy performed by trainees versus trained surgeons. Of 2,086 articles screened, 5 retrospective non-randomized comparative studies reporting on 10,019 participants were analyzed. There was no difference in overall complications (OR 0.92; 95% CI 0.76, 1.12; P = 0.42), major complications [Clavien-Dindo (CD) III/IV] (OR 1.18; 95% CI 0.71, 1.97; P = 0.52), minor complications (CD I/II) (OR 1.13; 95% CI 0.57, 2.27; P = 0.72), post-op ileus (OR 0.74; 95% CI 0.10, 5.26; P = 0.76), wound infections (OR 0.87; 95% CI 0.62, 1.21; P = 0.41), abscess formation (OR 0.58; 95% CI 0.28, 1.22; P = 0.15), operation times [Mean Difference (MD) 2.31 min; 95% CI - 4.94, 9.56; P = 0.53] and reoperation rate (OR 1.22; 95% CI 0.23, 6.42; P = 0.81). Trainees had fewer conversions to open appendicectomy (OR 0.14; 95% CI 0.02, 0.88; P = 0.04). Appendicectomy performed on pediatric patients by trainees did not compromise patient safety. LEVEL OF EVIDENCE: III.

Factors affecting operative autonomy and performance during otolaryngology training: A multicenter trial

Objective

Surgical education is changing in an era of new regulations and evolving training cultures. We sought to understand the factors that affect operative experiences during otolaryngology residency.

Methods

From December 2019 to December 2020, five otolaryngology training programs used the SIMPL OR smartphone application to evaluate residents after each operation. Residents and attendings rated the trainee's autonomy on a 4‐level Zwisch scale, performance on a 5‐level scale, and case complexity on a 3‐level scale. We examined associations between ratings of autonomy and performance with variables including postgraduate year (PGY), case complexity, gender, week of the academic year (AY), and whether multiple procedures were logged.

Results

78 attendings and 92 residents logged 2984 evaluations. PGY level and week of the AY were positively associated with attending ratings of autonomy and performance (PGY3 vs. PGY2: B = 0.63, p < .001 for autonomy and B = 1.05, p < .001 for performance; week of the AY: B = 0.013, p = .002 for autonomy; B = 0.025, p < .001 for performance). Multiple procedures logged and increasing case complexity were negatively associated with attending ratings (multiple procedures: B = −0.19, p = .04 for autonomy and B = −0.48, p < .001 for performance; hardest vs. easiest 1/3 of cases: B = −1.01, p < .001 for autonomy and B = −0.59, p < .001 for performance). Attending and trainee genders were not associated with attending ratings of autonomy or performance.

Conclusion

Resident autonomy and performance were positively associated with PGY level and week of the academic year, and negatively associated with case complexity and multiple procedures. These findings highlight the need to align training level with case complexity to promote quality operative experiences.

Level of Evidence

2.

The Resident-Run Minor Surgery Clinic: A Four-Year Analysis of Patient Outcomes, Satisfaction, and Resident Education

OBJECTIVE

A resident-run minor surgery clinic was developed to increase resident procedural autonomy. We evaluated whether 1) there was a significant difference between complications and patient satisfaction when procedures were independently performed by surgical residents vs. a surgical attending and 2) if participation was associated with an increase in resident procedural confidence.

DESIGN

Third year general surgery residents participated in a weekly procedure clinic from 2014-2018. Post-procedure complications and patient satisfaction were compared between patients operated on by residents vs. the staff surgeon. Residents were surveyed regarding their confidence in independently performing a variety of clinic-based patient care tasks.

SETTING

Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program.

PARTICIPANTS

Post-graduate year three general surgery residents that ran the clinic as part of a general surgery rotation.

RESULTS

1230 patients underwent 1592 procedures (612 in resident clinic, 980 in attending clinic). There was no significant difference in the 30-day complication rate between patients operated on by the resident vs. attending (2.5% vs. 1.9%, p = 0.49). 459 patient satisfaction surveys were administered with a 79.1% response rate. There was no significant difference in the overall quality of care rating between residents and the attending surgeon (87.5% top-box rating vs. 93.1%, p = 0.15). Twenty-one residents completed both a pre- and post-rotation survey (77.8% response rate). The proportion of residents indicating that they could independently perform a variety of patient care tasks significantly increased across the rotation (all p < 0.05).

CONCLUSION

Mid-level general surgery residents can independently perform office-based procedures without detriment to safety or patient satisfaction. The resident-run procedure clinic serves as an environment for residents to grow in confidence in both technical and non-technical skills. Given the high rate at which patients provide resident feedback, future work may investigate how to best incorporate patient derived evaluations into resident assessment.

APDS Presidential Address: Of Wrestlers, Mountain Bikers, and Surgeons -"The Way it is. . . .?"

Association of Program Directors in Surgery - Spring Meeting: Boston, MA Presidential Address April 28th, 2021 Benjamin Jarman, MD.

General Surgical Resident Operative Autonomy vs Patient Outcomes: Are we Compromising Training without Net Benefit to Hospitals or Patients?

OBJECTIVE

Resident operative autonomy has been steadily declining. The reasons are multifactorial and include concerns related to patient safety and operating room efficiency. Simultaneously, faculty have expressed that residents are less prepared for independent practice. We sought to understand the effect of decreasing resident autonomy on patient outcomes and operative duration.

DESIGN

Retrospective study utilizing the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database.

SETTING

Operative cases within the VASQIP database from July 1, 2004-September 30, 2019 were analyzed.

PARTICIPANTS

All adult patients who underwent a surgical procedure from July 1, 2004 to September 30, 2019 were analyzed. The subpopulation of patients that underwent a surgical procedure in General Surgery or Peripheral Vascular Surgery were identified based on the code of the specialty surgeon. Within these subgroups, the most frequent cases by current procedural terminology (CPT) code were selected for study inclusion. The principle CPT code of all cases was further coded by level of supervision: attending primary surgeon (AP); attending and resident (AR), or resident primary with the attending supervising but not scrubbed (RP). Baseline demographics, operative variables, and outcomes were compared between groups.

RESULTS

The VASQIP database included 698,391 total general/vascular surgery cases. 38,483 (6%) of them were RP cases. Analysis revealed that the top 5 RP cases account for 73% of total RP volume-these include: 1) Hernias (55% total; 33% open inguinal, 13% umbilical, 5% open ventral/incisional, and 4% laparoscopic) 2) cholecystectomy (18%), 3) Amputations (17% total; 10% above knee, 7% below knee), 4) Appendectomy (7%) and 5) Open colectomy (3%). The percentage of cases at teaching hospitals that were RP cases significantly decreased from 15% in 2004 to 5% in 2019 (p < 0.001). RP cases were generally sicker as demonstrated by higher ASA classifications and more likely to be emergent cases. Operative times were also increased with resident involvement, but RP cases were faster than AR cases on average. After adjusting for baseline demographics, case type, and year of procedure, mortality was no different between groups. Complications were higher in the AR group but not in the RP group.

CONCLUSIONS

The rate of resident autonomy in routine general surgery cases has decreased by two-thirds over the 15-year study period. Cases performed by residents without an attending surgeon scrubbed were performed faster than cases performed by a resident and attending together and there was no increase in patient morbidity or mortality when residents performed cases independently. The erosion of resident autonomy is not justified based upon operative time or patient outcomes. Efforts to increase surgical resident operative autonomy are needed.

General Surgery Resident Autonomy: Truth and Myth

Within general surgery education circles, the state of autonomy for residents in surgery training programs has been of growing concern. Although there is no direct evidence showing less autonomy in modern surgical training, multiple surrogates have been cited as reasons for concern. Many reasons have been given for lost autonomy including the 80-hour work week, financial constraints, concerns over quality of patient care, patient expectations, new and innovative technologies, legal limitations, and public opinion. This article discusses the current state of general surgery resident autonomy, why autonomy is important, barriers to autonomy, and ways to support autonomy.

Public perceptions of general surgery resident training and assessment

BACKGROUND

Patients play a crucial role in surgical training, but little is known about the public's knowledge of general surgery training structure or opinion of resident assessment. Our aim was to evaluate the public's knowledge of general surgery training and assessment processes.

METHODS

We administered an anonymous, electronic survey to US adult panelists using SurveyGizmo. We used Dillman's Tailored Design Method to optimize response rate. Questions pertained to demographics, knowledge of general surgery training structure, and opinions regarding resident assessment. Outcome measures included public knowledge of the structure of general surgery residency and the perceptions of resident assessment. Univariate and multivariate statistics were used as appropriate.

RESULTS

Survey response rate was 93% (2005 of 2148). Respondents had nationally representative demographics. Most respondents had health insurance (87%). Sixty-one percent of respondents believed that 100% of hospitals trained residents. Age <40 years, Black race (odds ratio 1.48 [95% confidence interval (CI) 1.11-1.96]), working in a hospital/health care field (odds ratio 1.49 [95% CI 1.12-1.97]), and having a family member/close acquaintance working in a hospital/health care field (odds ratio 1.53 [95% CI .20-1.94]) were associated with this belief. There was a preference to obtain online information about medical training (30% television [TV] shows, 24% Internet searches, 5% social media). Eighty percent of respondents felt that resident self-assessment and patient assessment of residents was "important" or "essential" when considering readiness for independent practice.

CONCLUSION

The US public has limited knowledge of general surgery training and competency assessment. Public educational strategies may help inform patients about the structure of training and assessment of trainees to improve engagement of these important stakeholders in surgical training.