Friday, February 15, 2013

Breaking news! Operations take longer when residents are involved

Yes, you heard it here first. A new study shows that for six common laparoscopic procedures, resident participation resulted in the surgery lasting from 20% to 47% longer.

The six laparoscopic operations were appendectomy, cholecystectomy, gastric bypass, fundoplication, colectomy, and inguinal hernia.

The paper, published in the Journal of the American College of Surgeons, culled the frequently mined NSQIP database for information on 89,720 operations. The database receives input from a large number of US hospitals, both teaching and non-teaching.

The key results were as follows:

All of the time differences are statistically and clinically significant.

Hospital length of stays for all groups did not show important differences. Cases involving residents were associated with significantly more morbidity for all procedures except inguinal herniorrhaphy and fundoplication. The authors feel that the increased morbidity seen was not clinically significant. It isn’t clear upon what they based that feeling. There was no difference in mortality rates for the two groups for any operation.

In no less than four places in the text, the statements similar to the following were made. “The presence of a resident during a surgical procedure is a surrogate marker for a learning environment in which there are likely to be other health care learners at each of the stations in the operating room.” The other health care learners might be anesthesia residents, medical students, nursing students or others.

This is a completely unfounded assumption. For example, in three hospitals I worked in over the years, we had a surgical residency training program with no anesthesia residents and no student nurses. Conversely, it is certainly possible to have no residents but have training programs for student nurses or scrub techs.

The authors rightly point out that the increased operative duration associated with resident training translates into some inefficiencies. A single operating room might not be able to process as many cases as it could when cases are done by attending surgeons. Also, longer cases might cost someone (third-party payer? patient?) more money since OR costs are tallied by the minute.

The paper concludes, “Additional work must be undertaken to identify strategies to optimize operating room efficiency and to develop alternate strategies to prepare participants for the performance of the procedure.”

And what would those “alternate strategies” be? You can pick up beads on a simulator all you want, but it’s not the same as doing an operation. And assuming open surgery is still being done somewhere, there is no simulator for open surgery.


Justin said...

Seems there have been a lot of publications about how residents are bad, and attendings are awesome. I'm just waiting for us to have Level I evidence we shouldn't train residents.

Skeptical Scalpel said...

Good point. We may be heading that way. As we face a possible shortage of general surgeons, we should be finding ways to enhance training, not derogate it.

RuggerMD said...

It always amazes me that people do blatantly obvious surgery.
Guess they have to pad the CV.

Skeptical Scalpel said...

I assume you meant obvious research. I agree. That's why i wrote the blog.

ruggerMD said...

Oh yea, research. Thanks.
I think the only blatantly obvious surgery lately I have seen is the CT scan showing appendicitis. LOL

Anonymous said...

The surgeons today were once residents too! If the residents today are not trained, WHAT HAPPENS TO TOMORROW?

Skeptical Scalpel said...

Anon, that is an excellent question.

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