1
|
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.
Collapse
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
| |
Collapse
|
2
|
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.
Collapse
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.
| |
Collapse
|
3
|
Abahuje E, Smith KS, Amortegui D, Eng JS, Philbin SE, Verma R, Dastoor JD, Schlick C, Ma M, Mackiewicz NI, Choi JN, Greenberg J, Johnson J, Bilimoria KY, Hu YY. See One, Do One, Improve One's Wellness: Resident Autonomy in US General Surgery Programs, A Mixed-methods Study. Ann Surg 2023; 278:1045-1052. [PMID: 37450707 DOI: 10.1097/sla.0000000000006002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVE We sought to examine the factors associated with resident perceptions of autonomy and to characterize the relationship between resident autonomy and wellness. BACKGROUND Concerns exist that resident autonomy is decreasing, impacting competence. METHODS Quantitative data were collected through a cross-sectional survey administered after the 2020 ABSITE. Qualitative data were collected through interviews and focus groups with residents and faculty at 15 programs. RESULTS Seven thousand two hundred thirty-three residents (85.5% response rate) from 324 programs completed the survey. Of 5139 residents with complete data, 4424 (82.2%) reported appropriate autonomy, and these residents were less likely to experience burnout [odds ratio (OR) 0.69; 95% CI 0.58-0.83], suicidality (OR 0.69; 95% CI 0.54-0.89), and thoughts of leaving their programs (OR 0.45; 95% CI 0.37-0.54). Women were less likely to report appropriate autonomy (OR 0.81; 95% CI 0.68-0.97). Residents were more likely to report appropriate autonomy if they also reported satisfaction with their workload (OR 1.65; 95% CI 1.28-2.11), work-life balance (OR 2.01; 95% CI 1.57-2.58), faculty engagement (OR 3.55; 95% CI 2.86-4.35), resident camaraderie (OR 2.23; 95% CI, 1.78-2.79), and efficiency and resources (OR 2.37; 95% CI 1.95-2.88). Qualitative data revealed that (1) autonomy gives meaning to the clinical experience of residency, (2) multiple factors create barriers to autonomy, and (3) autonomy is not inherent to the training paradigm, requiring residents to learn behaviors to "earn" it. CONCLUSION Autonomy is not considered an inherent part of the training paradigm such that residents can assume that they will achieve it. Resources to function autonomously should be allocated equitably to support all residents' educational growth and wellness.
Collapse
Affiliation(s)
- Egide Abahuje
- Northwestern QUality Improvement, Research, and Education in Surgery (NSQUIRES), Department of Surgery, Northwestern University, Chicago, IL
| | - Kathryn S Smith
- Northwestern QUality Improvement, Research, and Education in Surgery (NSQUIRES), Department of Surgery, Northwestern University, Chicago, IL
| | - Daniela Amortegui
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Indiana University, Indianapolis, IN
| | - Joshua S Eng
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Indiana University, Indianapolis, IN
| | - Sarah E Philbin
- Center for Education in Health Sciences, Northwestern University, Chicago, IL
| | - Rhea Verma
- Northwestern QUality Improvement, Research, and Education in Surgery (NSQUIRES), Department of Surgery, Northwestern University, Chicago, IL
| | - Jehannaz Dinyar Dastoor
- Northwestern QUality Improvement, Research, and Education in Surgery (NSQUIRES), Department of Surgery, Northwestern University, Chicago, IL
| | - Cary Schlick
- Northwestern QUality Improvement, Research, and Education in Surgery (NSQUIRES), Department of Surgery, Northwestern University, Chicago, IL
| | - Meixi Ma
- Northwestern QUality Improvement, Research, and Education in Surgery (NSQUIRES), Department of Surgery, Northwestern University, Chicago, IL
| | - Natalia I Mackiewicz
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Indiana University, Indianapolis, IN
| | | | | | - Julie Johnson
- Northwestern QUality Improvement, Research, and Education in Surgery (NSQUIRES), Department of Surgery, Northwestern University, Chicago, IL
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Indiana University, Indianapolis, IN
| | - Yue-Yung Hu
- Northwestern QUality Improvement, Research, and Education in Surgery (NSQUIRES), Department of Surgery, Northwestern University, Chicago, IL
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University, Chicago, IL
| |
Collapse
|
4
|
Hoagland D, Olasky J, Kent TS, Vosburg RW. The Impact of Trainee Involvement on Outcomes in Metabolic and Bariatric Surgery. Obes Surg 2023; 33:3454-3462. [PMID: 37755646 DOI: 10.1007/s11695-023-06831-9] [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: 07/11/2023] [Revised: 08/24/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND The number of bariatric operations performed in the USA rises annually. Trainee exposure to this field is necessary to ensure competency in future surgical generations. However, the safety of trainee involvement of these operations has been called into question. OBJECTIVES The aim of our study is to describe differences in outcomes between trainees and non-trainees as first assistants (FA) in sleeve gastrectomy (SG). SETTING The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database METHODS: Patients from the MBSAQIP database who underwent primary SG from 2015 to 2020 were identified. Statistical analysis included two-tailed t-tests and χ2-tests to evaluate the impact of trainees (residents and fellows) compared to non-trainees on post-operative morbidity and operative time. RESULTS Of the 559,324 cases, 25.8% were performed with trainees as FA. Operative length was 27.9% longer in trainee cases. In the trainee group, there was a higher risk of conversion to open procedure (OR 1.32), readmission (OR 1.19), and specific complications (cardiac arrest, myocardial infarction, progressive renal insufficiency, pulmonary embolism, sepsis, transfusion, intubation, UTI, VTE, ICU admission, and reintervention), though overall rates were < 1% in each group. Non-trainees had a higher rate of septic shock (OR 1.4). No significant difference was seen in all other perioperative outcomes. CONCLUSION Trainee involvement in SG leads to longer operative times without a clinically significant increase in morbidity and mortality. Such findings should be used to counsel patients and shape expectations for surgeons and hospitals. A focused bariatric surgery trainee curriculum may lessen this gap.
Collapse
Affiliation(s)
- Darian Hoagland
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Jaisa Olasky
- Department of Surgery, Lenox Hill Hospital, New York, USA
| | - Tara S Kent
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - R Wesley Vosburg
- Department of surgery Mount Auburn Hospital, Harvard Medical School, 355 Waverley Oaks rd, suite 100, Waltham, MA, 02452, USA.
| |
Collapse
|
5
|
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.
| |
Collapse
|