Resident Participation in Surgery: Analysis and Opinion

A recent column about resident involvement in the operating room by surgeon Pauline Chen in the NY Times has drawn a fair number of comments as has a similar post by blogger KevinMD. Both refer to a paper published on-line in the Journal of the American College of Surgeons. The abstract of the paper suggests that the presence of residents in the operating room is associated with somewhat higher rates of short-term morbidity and complications but lower mortality rates.

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 in the operating room has any impact on the development of postoperative complications such as urinary tract infection, venous thromboembolism, renal insufficiency, cardiac events or neurologic events.

Furthermore, the supposed mortality benefit of having residents was seen mostly in the most complex cases. Obviously, a number of confounding variables (attending surgeon experience, nursing experience, hospital and surgeon volume, ICU care, to name a few) may affect the outcome of a complex case. Also, the authors did not describe the level of resident participation. Were the residents merely holding retractors and assisting or did they perform significant portions of the procedure? This information was not available due to the retrospective nature of the study.

Most importantly, 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”

I agree with many of those who commented regarding the following points:

Asking the attending surgeon to exclude residents leads to differences in postoperative routines and may result in poor outcomes. The attending surgeon is not in the hospital 24/7. If you get sick at night, it is better to have residents who are familiar with your case see you.

The only way for residents to learn how to be surgeons is to perform surgery. It is not fair to take advantage of the positive attributes of a teaching hospital and ask that residents not be involved.

If you don’t want residents in the OR and/or taking care of you, choose a non-teaching hospital. In teaching hospitals, residents are part of the package.

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