An Ethical Framework for Disclosing the Training Status and Roles of Resident-Level Surgeons to Patients

The concept of informed consent includes disclosure of all information that a reasonable patient would need to make a well-informed decision about whether to undergo a surgical procedure. This has traditionally been defined as including diagnosis, details about the procedure, prognosis, potential risks, and alternative treatments. The operating surgeon has final say and responsibility for the case, but the actual operation may be done (under supervision) by a surgeon in training. In this paper, we discuss the ethical dimensions of disclosing resident involvement, reviewing considerations such as established legal and professional standards, consequences for patients and for the surgical educators responsible for preparing future generations of surgeons, and patient rights. We conclude by offering a novel ethical framework intended to serve as a guide to disclosing resident involvement as part of the overall consent process.

Evaluation Tools for Assessing Autonomy of Surgical Residents in the Operating Room and Factors Influencing Access to Autonomy: A Systematic Literature Review

BACKGROUND

Surgical residents in France lack a clear pedagogical framework for achieving autonomy in the operating room. The progressive acquisition of surgical autonomy is a determining factor in the confidence of operators for their future independent practice. Currently, there is no autonomy scale commonly used in Europe. The objective of this study is to identify existing tools for quantifying the autonomy of residents and the factors that influence it.

MATERIALS AND METHODS

We conducted a qualitative systematic review following the recommendations of the Systematic Review Without Meta-Analysis (SWiM) guidelines. Publications were extracted from the MEDLINE (PubMed), EMBASE, and PSYCINFO databases. All publications without date restrictions up to July 2022 were identified.

RESULTS

Among the 231 identified publications, 21 met the inclusion criteria. Seventeen publications used a graded autonomy assessment tool by the student and/or the teacher, while 4 used evaluations by an observing third party. We found 8 different autonomy scales, with the Zwisch Scale representing 57.1% of the cases. Factors influencing autonomy were diverse, including the work context, experience, and gender of the resident and their teacher.

DISCUSSION

We found heterogeneity in the tools used to "measure" the autonomy of a resident in the operating room. The SIMPL tool or the Zwisch Scale appear to be the most frequently used tools. The relationship between autonomy, performance, confidence, and knowledge may require multidimensional tools that encompass various areas of competence, but this could make their daily application more challenging. The factors influencing autonomy are numerous; and understanding them would improve teaching in the operating room. There is a significant lack of data on surgical autonomy in France, as well as a lack of evaluation in the field of gynecology-obstetrics worldwide.

Operating room organization and surgical performance: a systematic review

BACKGROUND

Organizational factors may influence surgical outcomes, regardless of extensively studied factors such as patient preoperative risk and surgical complexity. This study was designed to explore how operating room organization determines surgical performance and to identify gaps in the literature that necessitate further investigation.

METHODS

We conducted a systematic review according to PRISMA guidelines to identify original studies in Pubmed and Scopus from January 1, 2000 to December 31, 2019. Studies evaluating the association between five determinants (team composition, stability, teamwork, work scheduling, disturbing elements) and three outcomes (operative time, patient safety, costs) were included. Methodology was assessed based on criteria such as multicentric investigation, accurate population description, and study design.

RESULTS

Out of 2625 studies, 76 met inclusion criteria. Of these, 34 (44.7%) investigated surgical team composition, 15 (19.7%) team stability, 11 (14.5%) teamwork, 9 (11.8%) scheduling, and 7 (9.2%) examined the occurrence of disturbing elements in the operating room. The participation of surgical residents appeared to impact patient outcomes. Employing specialized and stable teams in dedicated operating rooms showed improvements in outcomes. Optimization of teamwork reduced operative time, while poor teamwork increased morbidity and costs. Disturbances and communication failures in the operating room negatively affected operative time and surgical safety.

CONCLUSION

While limited, existing scientific evidence suggests that operating room staffing and environment significantly influences patient outcomes. Prioritizing further research on these organizational drivers is key to enhancing surgical performance.

The RVU Compensation Model and Head and Neck Surgical Education

BACKGROUND

The present study aims to quantify the opportunity cost of training residents and fellows for head and neck surgery.

METHODS

A 2005-2015 review of ablative head and neck surgical procedures was performed using the National Surgical Quality Improvement Program (NSQIP). Work relative value units (wRVU) generated per hour were compared among procedures performed by attendings alone, attendings with residents, and attendings with fellows.

RESULTS

Among 34,078 ablative procedures, the rate of wRVU generation per hour was greatest for attendings alone (10.3), followed by attendings with residents (8.9) and attendings with fellows (7.0, p < 0.001). Resident and fellow involvement was associated with opportunity costs of $60.44 per hour (95% CI: $50.21-$70.66/h) and $78.98 per hour ($63.10-$94.87/h, 95% CI), respectively.

CONCLUSION

wRVU-based physician reimbursement does not consider or adjust for the extra effort involved in training future head and neck surgeons.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:113-119, 2024.

Does length of time between cases affect resident operative time for tonsillectomy and adenoidectomy?

OBJECTIVE

To evaluate the effect of prolonged time intervals between tonsillectomy and adenoidectomy (TA) on resident operative time and complications.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary academic hospital.

METHODS

This retrospective study covers a five-year period from 2015 to 2020. Time intervals between isolated pediatric TA cases performed by eight otolaryngology residents were reviewed to assess effect on operative time (defined as prolonged if ≥ 30 min and non-prolonged if < 30 min). Intervals including a procedure involving either a tonsillectomy or adenoidectomy that was a non-isolated TA were excluded.

RESULTS

A total of 309 isolated TAs were identified with 67.3% of procedures performed under 30 min. The mean surgical time interval between procedures was 5.83 ± 10.02 days (range 0.02-69.82). Most TAs were performed on patients aged 7 years or younger. Surgical time interval between TA was not a significant factor in determining prolonged operative time on univariable logistic regression, OR 1.01 (CI: 0.98 to 1.03) (p = 0.63). Patient age at surgery, adenoid grade, tonsil size and total number of TAs performed to date were significant factors in determining prolonged operative time in both univariable and multivariable logistic regression models. Prolonged operative time did not have a significant effect on readmission, reoperation, or post-operative bleeding.

CONCLUSION

Extended time interval (up to 3 months) between routine TA does not affect operative time. Expansion of our methodology to more complex cases would be beneficial in designing resident training curriculum.

[Multimodal training concept for temporal bone surgery]

BACKGROUND

Surgical training is increasingly supported by the use of simulators. For temporal bone surgery, shown here by means of mastoidectomy, there are other training models besides cadaver specimens, such as artificial temporal bones or computer-based simulators.

OBJECTIVES

A structured training concept was created which integrates different training methods of mastoidectomy with regard to effectiveness and current learning theory in education.

METHOD

A selective literature research was conducted to compare learning-theoretical findings and the availability and effectiveness of currently existing training models.

RESULTS

To acquire surgical skills, a stepwise approach is suggested. Depending on the progress with computer-based simulation, plastic or native temporal bones should be used. To achieve a plateau of the learning curve, approximately 25 semi-autonomous preparations are recommended. Different 'Objective Structured Assessments of Technical Skills' (OSATS) are implemented to assess the learning progress at different levels.

DISCUSSION

Simulation-based training is recommended until an adequate learning curve plateau is achieved. This is reasonable for patient safety, based on limited accessibility of human cadaveric temporal bones but also by findings of the learning theory.

CONCLUSION

The curriculum integrates different training models of mastoidectomy and OSATS into an overall concept. The training plan has to be continuously adapted to new findings and technical developments.

Evaluating resident involvement and the 'July effect' in parotidectomy

OBJECTIVE

This study aimed to evaluate the effect of resident involvement and the 'July effect' on peri-operative complications after parotidectomy.

METHOD

The American College of Surgeons National Surgical Quality Improvement Program database was queried for parotidectomy procedures with resident involvement between 2005 and 2014.

RESULTS

There were 11 733 cases were identified, of which 932 involved resident participation (7.9 per cent). Resident involvement resulted in a significantly lower reoperation rate (adjusted odds ratio, 0.18; 95 per cent confidence interval, 0.05-0.73; p = 0.02) and readmission rate (adjusted odds ratios 0.30; 95 per cent confidence interval, 0.11-0.80; p = 0.02). However, resident involvement was associated with a mean 24 minutes longer adjusted operative time and 23.5 per cent longer adjusted total hospital length of stay (respective p < 0.01). No significant difference in surgical or medical complication rates or mortality was found when comparing cases among academic quarters.

CONCLUSION

Resident participation is associated with significantly decreased reoperation and readmission rates as well as longer mean operative times and total length of stay. Resident transitions during July are not associated with increased risk of adverse peri-operative outcomes after parotidectomy.

Preoperative Criteria Predict Operative Time Variability Within Tympanoplasty Procedures

OBJECTIVE

To identify preoperative patient and surgical parameters that predict operative time variability within tympanoplasty current procedural terminology (CPT) codes.

STUDY DESIGN

Retrospective.

SETTING

Tertiary referral center.

PATIENTS

One hundred twenty eight patients who underwent tympanoplasty (CPT code 69631) or tympanoplasty with ossicular chain reconstruction (69633) by a single surgeon over 3 years.

INTERVENTIONS

Procedures were preoperatively assigned a complexity modifier: Level 1 (small or posterior perforation able to be repaired via transcanal approach), Level 2 (large perforation or other factor requiring postauricular approach), or Level 3 (cholesteatoma or severe infection).

MAIN OUTCOME MEASURES

Total in-room time (nonoperative time plus actual operative time).

RESULTS

Consideration of preoperative parameters including surgical complexity, surgical facility, use of facial nerve monitoring, laser usage, resident involvement, revision surgery, and underlying patient characteristics (American Society of Anesthesiologists [ASA] score, body mass index [BMI]) accounted for up to 69% of surgical time variance. Across both CPT codes, surgical complexity levels accurately stratified operative times (p < 0.05). Total time was longer (by 30.0 min for 69631, 55.4 min for 69633) in Level 3 procedures compared with Level 2, while Level 1 cases were shorter (27.6, 33.9 min). Resident involvement added 25 and 32 minutes to total time (p < 0.02). Nonoperative preparation times were longer (22.1, 15.4 min) in the main hospital compared with ambulatory surgical center (p < 0.001).

CONCLUSIONS

There is significant surgical time variability within tympanoplasty CPT codes, which can be accurately predicted by the preoperative assignment of complexity level modifiers and consideration of patient and surgical factors. Application of complexity modifiers can enable more efficient surgical scheduling.

Operation time effect on rates of perioperative complications after operative treatment of distal radius fractures

Purpose

The purpose is to identify the impact of operation time length on complications for patients undergoing operative treatment of distal radius fracture.

Methods

Patients who underwent operative treatments for distal radius fractures were identified in a national database. Data collected include patient demographic information, comorbidities, and complications.

Results

Operation time was found to be an independent predictor for return to the operating room. Operation time was not found to be a predictor of other postoperative complications.

Conclusion

Surgeons should work to shorten procedure duration whenever possible to minimize the risks that longer operative times can have on patient outcomes.

Predictive model of operative time in transoral endoscopic thyroidectomy vestibular approach

BACKGROUND

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) has demonstrated excellent safety and is receiving wider use in North America. Understanding which factors lead to operative difficulty, as evaluated by operative time (OT), may help to improve safety and refine indications for this procedure.

METHODS

Cases of TOETVA performed at our institution were reviewed. Multivariate linear regression was performed using patient demographics, thyroid characteristics, and operative variables to predict OT.

RESULTS

A total of 207 cases were included for analysis. A multivariate linear regression model, controlling for age, sex, and BMI, was developed from 104 cases with an R² of 0.47 (p < 0.001). Cross-validation on 103 remaining cases showed root-mean-square error of 46.37. Total thyroidectomy and lobe size were the only significant predictors (p < 0.001).

CONCLUSIONS

We successfully developed a model to predict OT for TOETVA based on preoperative and operative variables. Lobe size, but not BMI, is a significant predictor of OT.

The Cost of the "July Effect" in Microsurgery

The existence of the "July effect," or the idea that the new academic year intrinsically has an increased complication rate is evaluated in microsurgical free tissue transfer procedures. The National Surgical Quality Improvement Program registry was queried for all free flap procedures performed between 2005 and 2016 (n = 3405). Cases were grouped as having occurred in the first academic quarter (Q1: July 1-September 30) or fourth quarter (Q4: April 1-June 30). Demographical data and complications were compared using univariate χ analysis, multivariate logistic regression was used to control for confounding variables, and inpatient stay and operating cost estimates were created. Of a total of 1722 cases, 905 were performed in the first academic quarter and 817 were performed in the fourth academic quarter. There was no significant difference between Q1 and Q4 in readmission rate (P = 0.378) or reoperation rate (P = 0.730). Patients in Q1 had significantly longer operative times (P = 0.001) and length of stay (P = 0.002) compared with those in Q4. In addition, cost of inpatient stay and operating costs associated with each free flap were significantly increased in Q1 compared with Q4 (P = 0.029; P = 0.001). The total cost per quarter for free flaps was also significantly more expensive in Q1 vs Q4, with the highest average difference in cost of $350,010.64 (P = 0.001). Having surgery early in the academic year does not put patients at any increased risk for major complications but is associated with increased operating time, length of stay, and total cost.