Residents assisting with your surgery can save lives, but at a cost

When undergoing surgery, would you want interns and residents present, and perhaps, assisting in the operation?

That’s a question patients face when going to an academic medical center.  Some won’t mind the presence of house staff.  Some will.

A recent study provides some details on the outcomes.

In a column by Pauline Chen in the New York Times’ Well blog, she notes that,

The Journal of the American College of Surgeons published the results of a study on how well patients come through when a surgeon-in-training is involved in the operation. Analyzing the results of more than 600,000 operations at more than 225 hospitals across the country, researchers found that while resident involvement was indeed associated with slightly higher complication rates and longer operating times, those patients who had trainees participating in their operations also experienced decreased mortality rates.

So the question becomes, would patients rather have a slightly higher chance of a minor complication, in exchange for a slightly improved mortality rate?

Or, as the lead author puts it, “Would you accept the risk of a urinary tract infection that required an antibiotic for several days if you knew it might save your life?”

It’s unclear why having interns and residents present decreases mortality. One hypothesis is that having a team present can prevent the cascading “domino” effect of progressively worsening complications, rather than a single surgeon.

Another could be that more eyes on the patient can catch potential medical errors.

The downside, of course, is that residents involved in the procedure won’t be as technically accomplished, thus leading to a higher complication rate.

The ultimate decision is in the hands of the patient. Now, armed with this data, they can make better informed decisions whether they want residents and interns involved with their surgical procedure.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Mark

    I wish you had said that if you choose not to have interns/residents involved, then it’s better not to go to an academic medical center in the first place. Screwing with the normal workflow of a hospital will just make your stay even more dangerous.

  • L.

    I followed this debate on NYT WellBlog. After reading through the article and all the comments, I decided that YES, I would want residents involved in my surgery & care, BUT ONLY if the attending physician were closely involved at all times AND the attending surgeon was COMPLETELY HONEST about it all. What I would not accept is obfuscation – patronizing obfuscation – the kind where the patient asks if the attending will supervise and defines “supervise” as present and actively observing ALL THE CRITICAL parts – and the attending, knowing full well what the patient means – wink, wink, nod, nod – says yes – but knows that HIS definition means he’ll be “available” if something goes wrong. And, yes – I expect the attending to be present and actively observing even when it’s a senior or chief resident who is in charge. At no time would I consent to a surgery by a resident without the attending present and observing every critical step of the way. If you want to assign my procedure to a chief resident, then I must meet this person and know going in that he/she will be in charge. DO NOT LIE TO ME. Do not justify your lies by having your own secret definitions of “supervise” and “participate.”

    The research article (which I did not read) says there are “more complications.” It did not say “minor” complications. There is an unfortunate story (http://bit.ly/gPINim) that ended in an amputation where the attending surgeon (after assuring the patient he would personally be doing the surgery, a knee replacement) assigned a senior resident who in turn delegated it to a 2nd year resident (unsupervised), who made a critical error that would have been caught had he been properly supervised. The 2nd year in turn left rounding and after care post-op to students where pain reports were ignored (had they been taken seriously, the leg might have been saved) . So – the “complications” are not always so minor – and the residents and students – not always so “supervised.”

    ["The second-years are allowed to operate if a faculty member or a fourth-year is "physically present in facility or campus and is immediately available for consultation."'] – that’s not what I’m signing on for – and not something ANYONE would – so clearly there’s plenty of obfuscation going on. The priority, in this instance at least, is the teaching of the residents – NOT – the safety and well-being of the patients – and that is unacceptable ALWAYS. The harming of any patient for the sake of the education of a future surgeon is never, ever acceptable.

  • Bladedeoc

    ^^THIS^^

    I don’t treat anyone differently, VIP treatment only screws things up. If you don’t want residents to assist I will suggest you find another surgeon, at first gently and then firmly.

    • ninguem

      What bladedoc said. And that’s been touched on by Mark, too.

      I trained at two University medical centers for residency and fellowship. Agree completely. You do things differently to accommodate a VIP…….or placate someone who THINKS he’s a VIP…….that’s when you get into trouble.

      Example I use is VA hospitals. Now I’m primary care, solo office. Sometimes my patients have reason to go to a VA hospital. They ask my advice. I tell them to pick the VA that’s attached to a University medical center. Yes, it’s where the residents go to learn independence.

      It’s where I learned independence for that matter. It’s still better than the freestanding place where the doc may be “fully-trained” but not up-to-date and may not speak English for that matter.

      Hate to paint the VA system with that broad brush, but at least in my corner of the world, the VA’s I’ve seen, that’s what I see, and I stand by the story.

      When I taught at still another University medical center, I had the same demands, and I ran it up the administrative channels. Unanimous full support, the official line is it’s good enough for the President of the University, it’s good enough for everyone else, you want no resident involvement, go somewhere else.

      Demanding the attending around for “critical parts” sounds nice…..but the problem is, whatever goes wrong is the “critical” part in retrospect.

      The whole process of teaching involves the residents, the attendings, the senior residents teaching the junior residents, to the interns and medical students. That whole teaching process is what created the excellence that attracts people to the University center.

      Then someone goes to the University center and demands that the very thing that created the excellence…..not be applied……..

      Bizarre. Just go to a community hospital.

      • L.

        The attending is REQUIRED to be present for the critical parts – the attending is REQUIRED to supervise – as in BE IN THE O.R. Phantom surgery is illegal.

        Also – the surgeon needs to be completely honest so the patient can decide to go to a private practice. Lying to the patient in order to recruit patients for the residents to practice on is not acceptable.

        • daisyduck

          Surgeon is not required to be in the OR, just the OR suite. Surgeon can be supervising more than one room.

          • L.

            Not if he wants to bill for it – legally. Otherwise it’s fraud. He must be in the O.R. with the patient for the “critical” portions. How “critical” is defined I do not know. For all I know it’s the time out and he’s out of there.

            The bigger point here is the LYING about it to the patient. When a patient asks DIRECTLY and requests a DIRECT ANSWER – and is LIED to in order to recruit patients for just for the residents to practice on – because otherwise they’d lose some (but probably not many) of their patients to private hospitals. I call that unethical. No one’s denying that, I see.

          • ninguem

            I don’t have a problem with that. You go to a teaching hospital, you get house staff. Period. I don’t care for lying either. Someone promising no housestaff in a teaching hospital? Like going to a Kosher deli and asking for pork ribs, it ain’t happening.

          • L.

            No. It was the attending surgeon promising he would be personally involved – as in present and participating fully throughout, WITH the resident(s) not INSTEAD OF the resident(s). He told a lie – justified to himself, I believe, by his careful selection and use of certain terms – knowing that I (or any lay person) would define those terms differently. I wanted the residents involved. I needed the residents involved in my complex procedure – but I didn’t want to be left alone with them – which I was – and yes – there was a complication that most certainly would have been avoided had the attending actually attended the surgery. It was a rookie mistake. I knew it. He knew it. The resident knew it. I was betrayed. It was unconscionable. Loss of trust is not a good thing. I have made my experience known to others seeking care at that particular hospital. It may have had a small effect in their decision to seek care elsewhere. The light of the world is on you now. Better tread carefully. It was the LIE, not the DEED, that I cannot abide.

  • Amy

    When I was pregnant with triplets, I was seen at a teaching hospital by a maternal-fetal medicine specialist. No residents in all of my visits (I also work at a teaching institution as a nurse in the Operating room, so I know the “deal”). I was giving birth at the end of June. Anyone who knows teaching institutions knows that new residents start at the end of June. Each year, the start date is slightly different, but end of June-beginning of July is the “scary” time at teaching hospitals…MDs who were medical students last week are interns the next week…

    I specifically said, medical students could watch, but not do anything, I wanted the chief resident there until they finished closing skin, and no junior residents doing the closings. My attending stayed until the end, and closed the skin. Most people don’t know how it works in the OR. I know that going to a teaching institution comes with accepting resident/medical student care, but you do have a choice. Become informed, and make good decisions regarding you or your family’s care.

  • Sharon PT

    Does any patient ever get the full attention of the attending surgeon during an operation in a teaching hospital? If so, what might be the deciding factors?

  • soloFP

    What is supposed to happen and what actually happens can be quite different. In residency 10 years ago, the surgeons would stay for the main part, such as the GB/Appendix. They would let the resident start the surgery and then let the resident close up with supervision by the surgical techs, while the surgeon would go eat lunch or dictate records. That said, the patients with both residents and attendings seeing them did better, as a doctor was in the hospital 24 hours a day to see the patient’s condition for middle of the night calls. There are private docs in my community who don’t round until 8 pm at night the next day on AM surgeries. A lot can happen in 36 hours without the patient seeing doctor.

  • DrGreg

    I was an attending at a teaching hospital for over five years. Residents were present on virtually every surgical case. I concur that each case was longer because of their help, perhaps 10 to 15%. A benefit to their assisting was that on marathon OR days I felt fresher and more alert during the critical parts of the procedures.

    A skilled attending knows the capability of the residents and usually does not let them perform a maneuver that they are not capable of, or can not be easily fixed.

    As an attending in a teaching institution you must be academically on top of your game. Student’s will ask you questions on the latest therapy or technique and expect a intelligent response. Many of my colleagues are intimidated by the academic environment and avoid these institutions. A surgeon must be skilled and have confidence in his abilities because many eyes will be on him.

    The statistics may be biased toward academic institution because the attendings are that much better.

    • Sharon PT

      Dr. Greg, your confident explanation put this nervous patient a little more at ease. Thanks for not addressing patient concerns (reasonable or not) with ‘if you don’t like it, go to another hospital.’. Can you imagine how an already scared patient feels when they hear a threat like that?

  • http://fertilityfile.com IVF-MD

    How about the opposite? Is having residents doing a case ever superior than having a non-resident doing it? Hmmm…

    On reading this post, the following isolated anecdotal example comes to mind. It does not contradict the insightful comments above, but I must point out the following remote possibility.

    Picture a private hospital that is affiliated with an academic program whose residents rotate through that hospital. The senior residents, who have been excellently trained back at the university hospital with top-notch attendings, routinely scrub in on cases with the private doctors some of whom have a reputation with the OR nurses of being less than stellar. Suppose that some of these private doctors are old, initially trained three decades ago and not as up to date on the latest techniques. Every morning, when the chief looks at the OR schedule and assigns residents to cases, might it be possible that he/she thinks. “Hmm, Dr. So-And-So has a major case in room 2 that looks pretty complicated. I had better scrub in myself on this to keep him out of trouble”.

    Sure, you might have full faith in the ability of the system to keep unreliable old doctors from practicing, so if you do, then you can just ignore the possibility of this scenario as being anything other than fictional. But if you choose to be open-minded, you might just guess that perhaps what I’m describing has and does occur in real life.

  • Sharon PT

    I have to challenge the views of some that VIP’s are either treated the same or in some cases get worse treatment than ordinary patients. After following Rep. Gabrielle Giffords mesmerising treatment by university hospital doctors for her head gunshot wound, I can’t believe the hospital chief, when hearing of her arrival, even thought about assigning medical students or novice residents to her care, even though it would be a great learning experience for them. I doubt they were even allowed in the room.

    • ninguem

      Uh….no.

      It would be neurosurgery and trauma fellows for a gunshot wound to the head. No teaching facility is sending a medical student or an intern to manage a gunshot wound to the head.

      Part of the problem with VIP trauma can, in fact, be that the person who should care for the VIP trauma should be the one who has been taking care of the trauma of the gangbangers and the homeless, all along, and NOT some more senior individual who doesn’t do the work regularly, but suddenly feels a “duty” to be involved with this VIP case.

      • http://fertilityfile.com IVF-MD

        Great point. If I needed someone to take care of my GSW, I’d want the fellows or junior attendings who have been in the trenches successfully managing a dozen of these cases every week, rather than the venerable general surgery chairman who has been busy running the administration, writing grants and giving talks on bench research topics. I’ve witnessed specific cases where VIPs asked specifically for the chairman of the department to care for them even to the point one time of the starstruck chairman going to their home to administer injections and other nursing duties. All the while, the chairman consulted with us residents/fellows for specific advice on what to do. Amusing, but understandable.

        • ninguem

          I’ve heard that, on more than one occasion, from people who really were involved in a VIP trauma. Reagan’s shooting, as one example.

          They find they have to shoo off some of those types.

          “You know, we might eventually need your services as Chief of Infectious Disease, thanks for the offer, but please step back while we stop the bleeding.”

          That sort of thing.

        • ninguem

          IVF-MD – “…..I’ve witnessed specific cases where VIPs asked specifically for the chairman of the department to care for them…..”

          Same here. Some specialties require a certain number of years in practice before you can take your boards. “I want a BOARD-CERTIFIED doctor….” and the patient ended up turning down the superstar doc out of Fellowship at the top of his game, passed all the written Boards, to take the orals next year (he passed easily), and the patient ended up with the guy who was certified, but spends most of his time in the laboratory. I was an intern, I tried to talk the particular patient out of it, wouldn’t listen, OK fine.

          Everything went well, but there you are.

  • EmilyTran

    I have to challenge the views of some that VIP’s are either treated the same or in some cases get worse treatment than ordinary patients. After following Rep. Gabrielle Giffords mesmerising treatment by university hospital doctors for her head gunshot wound, I can’t believe the hospital chief, when hearing of her arrival, even thought about assigning medical students or novice residents to her care, even though it would be a great learning experience for them. I doubt they were even allowed in the room.

  • Lisamarie

    I had surgery at the same academic medical center where I got all my care (which was top-notch), done by a surgeon that the GI doctor I trusted recommended. Considering the resident did all my pre-op appts, it was not rocket science to figure out he would be doing the surgery. I knew the attending might be supervising 2 operations at once (learned that from a med student friend). But that’s how teaching hospitals work! It’s not like trained doctors grow on trees. I had a fairly serious complication, but it was a known one for this surgery that I had been warned about in advance, and I don’t hold the surgeon or residents responsible for that. The attending surgeon took over all my post-op care after the complication himself, and he did a good job (never saw resident again Wonder if he was in the doghouse for what happened). Generally, I roll my eyes at all the people who think they’re such special snowflakes that no unwashed rube resident should dare come near them. They’re usually the same ones that think other people should participate in clinical trials so they can take the best most effective medications once they’ve been tested on others. If you’re so special you need your medications tested and your residents trained on other people, go ahead find a non-teaching hospital that will cater to you.

  • http://skepticalscalpel.blogspot.com SkepticalScalpel

    As is the case for many medical topics on the Internet, everyone would benefit from reading the entire paper and not just the abstract. There are some issues. For example, the paper says that resident involvement leads to more complications. It is not clear to me how the presence or absence of a resident has any impact on the development of complications such as urinary tract infection, venous thromboembolism, renal insufficiency, cardiac events and more.

    Furthermore, the supposed mortality benefit of having residents was seen only in the most complex cases. Obviously, a number of confounding variables (university hospital, attending surgeon experience, nursing experience, etc) may affect the outcome of a complex case. The body of the paper (not the abstract) concludes as follows: “Ultimately, there appear to be no major, clinically significant differences in surgical outcomes based on resident involvement and patients and other stakeholders can be reassured that resident involvement in surgical care is safe”

    Disclosure: I was a surgical residency program director for 24 years.

  • Sharon PT

    The circumstances are much different when a hospital
    worker claims to prefer trainees in their care. They most likely know the trainees work history and skill level, seen
    them in action, or at the very least can easily vet them with
    colleagues before making any decision. The unconnected
    patient doesn’t have the privilege to chose a known
    talented trainee or access any information about them.
    We’ll probably never meet the person assisgned to us or even know their name, let alone if they were successful in their participation. For us, everything is based on blind trust, which unfortunately is sometimes violated to serve someone else’s agenda.

    Please be a little understanding of our fear and anxiety.

  • gzuckier

    Given that people have (unknowingly) had medical device salespeople operating on them, this question tends towards the minor effect size.

  • http://howtoliveonpurpose.com/emotions/family/positive-parenting/if-you-work-full-time-and-become-pregnant-with-triplets-what-are-your-child-care-options/ Kim

    I wish I had know how the hierarchy at teaching hospitals when I delivered my high risk pregnancy of quadruplets. I am convinced the resident messed up when she closed my c-section. The area has no feelings and the scar is uneven. I was under the mistaken impression that the MD would perform the c-section.

    People need to be more aware of how much experince each “type” of doctor has so thank you for this information.

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