Residents performing surgery: Why can’t we reach a middle ground?

A comparison of appendectomy outcomes for senior general surgeons and general surgery residents revealed no significant differences in early and late complication rates, use of diagnostic imaging, time from emergency department to operating room, incidence of complicated appendicitis, postop length of stay, and duration of post-op antibiotic treatment.

The only parameter in which a significant difference was seen was that attending surgeons completed the procedure significantly faster by 9 minutes — 39.9 vs. 48.6 minutes, but this may have been influenced by the fact that attending surgeons used laparoscopic staplers 13.5 percent of the time as opposed to use by the residents in only 2 percent of cases, also a significant difference.

This before-and-after study of more than 1,600 appendectomy patients was published in JAMA Surgery. Between 2008 and 2012, residents were permitted to perform appendectomies without direct supervision by an attending surgeon. The pre-2012 group included 548 operations performed by general surgery residents alone. Because of a policy change, all of the appendectomies from 2012 to 2015 were performed by attending surgeons alone or directly supervising a resident.

When I tweeted a link to the abstract of this paper, a number of people commented indignantly that unsupervised residents were a menace to society and such a heinous thing should not be allowed to occur. Never mind the data.

I have been writing about the problem of lack of autonomy for surgical residents since I first started blogging in 2010. In an early post, I quoted a former surgical program director who said one of the unintended consequences of increasing resident supervision was “residents never have the experience with practicing independently.” Many graduates of training lack confidence and take fellowships to gain additional experience.

In 2012, I wrote “Resident insecurity is related to a number of factors. To me, the most important of these is that residents almost never operate independently in the 21st century. There is much more supervision than there was in the past. This may be because of increased regulatory scrutiny, medicolegal considerations, and patient demand.”

The problem persists. A few months ago, I cited an address by John R. Potts, III, a former surgical program director and now senior vice-president of surgical accreditation for the ACGME, who said, “I have personally encountered individuals finishing general surgery residency programs who have never completed any operation — regardless how simple and basic — without an attending surgeon being with them throughout that operation.”

The paper I discussed at the beginning of this post was from surgeons at a medical school in Jerusalem, Israel, suggesting decreased resident autonomy is not limited to the U.S.

An accompanying editorial from the department of surgery at the University of Wisconsin commended the authors for publishing their work and pointed out that simulation does not compensate for real-life experience. I agree.

Can’t we reach a middle ground where for certain operations that have been successfully performed by a resident with an attending surgeon scrubbed or present in the operating room, said resident can be permitted to operate with the attending surgeon in the OR lounge or elsewhere in the hospital?

As I said in 2012, “For those who like the pilot/surgeon analogy [I don’t but use it when it supports my biases], would you like to fly with a pilot who had never soloed before? Better for a young surgeon to solo during residency when help is readily available than when she is in practice, don’t you think?”

“Skeptical Scalpel” is a surgeon who blogs at his self-titled site, Skeptical Scalpel.  

Image credit: Shutterstock.com

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