Thursday, May 4, 2017

Can surgical residents please have some autonomy?

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 postop 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% of the time as opposed to use by the residents in only 2% of cases, also a significant difference.

This before-and-after study of more than 1600 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.” [Emphasis by Dr. Potts]

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 US.

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?”


Unknown said...

So if the surgeon is not present, and the hospital is getting money for direct and indirect medical education from the government, does that mean that there will be no charge for the professional fee for the surgery unless there was a complication and the surgeon actually participated?

Skeptical Scalpel said...

That is a good question. I believe it is up to the individuals involved to decide how to handle that. When I was not present for a procedure done in or outside the OR, I did not bill the patient.

There are many issues that will have to be overcome for this to happen.

artiger said...

As to the question of billing, physicians bill incident to when they have midlevel providers working under them, don't they, even when not physically present to supervise? If so, I would think it would not be inappropriate for some sort of reduced professional fee when the attending is in the building but perhaps not physically in the OR during the case.

One other thing that stood out to me...almost 40 minutes on average for an attending to complete an appendectomy? Open or lap, that seems excessive. I know not everyone can get it done in 15-20 minutes, but that means to me that a significant chunk of attendings are really bringing the average up, taking an hour or more. That's concerning (at least to me).

Anonymous said...

As someone who is coming into a GS residency, I hope to dear god that I will be able to perform all basic procedures for a moderately complicated patient by the end of my training. That seems like a lot to ask for when I was on my interview trail.

These days 3/4 hospitals I did auditions at don't even let students type notes because it is apparently medicare fraud for residents and attendings to use student notes as H&Ps. Sure, these rules probably makes sense from a medicolegal stance, but it has a unintended consequence of taking away our autonomy and learning, and it makes us weak. This permeate from students all the way up. We are allowed to do less and less, and have to be in training more and more. These decisions benefits the hospital administrators, the lawyers, and patients who solely want "the best" without regard for looking at the medical training side of the system, and why should they? Training future surgeons is not their job. We need our staff and attendings for fight back against them to give us that autonomy. If everyone is operated on by the attending surgeon, where do the future surgeons get their experience? Who are you training to operate on you when you get older?

My whole generation has been the target of the previous generation making decision and policies that benefits itself, while ignoring those who follow. Be it financially, environmentally, and even in things like medical training. In fact, go and ask any 3rd/4th year medical students how they feel about their rotations, most will give you instances where they are just shadowing, SHADOWING, like what any high schoolers can do. We are coddled in the name of medicolegal reasons and then told how unprepared we are compared to your generation of doctors. Well we want to be great, but we just are not in the same environment anymore.

Oldfoolrn said...

Wow..have times changed. Back in the good old days my favorite attending surgeon just loved working as the scrub nurse or "Mayo nurse" in his vernacular. He would be happily slapping instruments while the resident served as the attending with me the "official" scrub nurse functioning as first assistant.

I never thought of the remuneration as I was quite content with $4.50 per hour. For a 3 hour trauma case I probably took home about 10 bucks.

Skeptical Scalpel said...

Artiger, yes the times were excessive. I alluded to that in the post. I don't know if it is a European thing or what.

Anon, I feel your pain, but please do not blame those who came before you. We are the victims of regulators, lawyers, insurance companies, and other outside forces. Most surgeons understand what needs to be done to train today's residents.

Old, I know exactly what you are talking about. I'm afraid those days are gone, probably forever.

Oldfoolrn said...

Dr. Skeptical, I think you meant "gone, HOPEFULLY forever." Big open surgeries and doing procedures on an empirical basis was not a great thing for patients. I did my best, but some of my memories of the good old days are cringe worthy!

Skeptical Scalpel said...

No, I am sorry that most residents are not allowed to operate independently. That's why they lack confidence.

Anonymous said...

Once residents are willing to take full responsibility for the outcomes of the case, then I am willing to allow them to do the case. Unfortunately, they rotate off service -- sometimes the day following an extensive operation -- and rarely (really, never) see the patients they have operated on back in clinic. Once they act a fully trained general surgeons, they can operate like them. Until then, I'll oversee my patients' operations.

Skeptical Scalpel said...

Thanks for commenting. I understand your frustration with residents failing to take responsibility for managing cases they do. However, many times they get mixed signals. For example, I've seen attendings make minor adjustments to IV orders and orders for labs. That sends a negative message to the residents who often respond by backing off.

Regarding rotating off the service. Unless we return to the pre-Halsted days of training surgeons by apprenticing them to senior barbers, there will be rotations, vacations, fellowship interviews, work hours limits, etc. To ask residents to see every patient they operate on for every single day of a hospitalization and in clinic too is probably unrealistic in 2017.

If you lay out your reasonable expectations early in their time with you, most residents will conform.

Vamsi Aribindi said...

One thing I just thought of- if the attendings were faster but were using laparoscopic staplers 13% of the time, what exactly were the residents using and what were they using 80% of the time? Were they passing a free suture and intracorporeally tying? The only thing besides a stapler I've ever seen in a lap appy is a harmonic to take down the mesoappendix, and maybe once an endoloop for the appendix... Are foreign lap appys done primarily without staplers?

Skeptical Scalpel said...

Vamsi, good questions. I don't know the answers. I emailed the corresponding author before I wrote the post but got no response.

Unknown said...

this epitomizes everything wrong with the medical industrial complex

Anonymous said...

Anonymous Europe: As a trainee what I can say is, that even here, because of the legal system, you are just not allowed to operate on your own... What I would find good is that if the trainer deems the trainee good enough, then he is allowed to perform operations with the trainer sitting in the OR lounge, where he can be called immediately if something happens.

Skeptical Scalpel said...

Unknown, you may be right but that is different from what I wrote about in the post. I am talking about residents lacking experience in conducting an operation because they graduate without ever having done it by themselves.

I have always been against simultaneous operations done for monetary gain and without the knowledge of the patients. You might be interested in this link

Anon Europe, that is the least we can do to foster some independence in our trainees.

Anonymous said...

Anon Australia: I posted something earlier but it seems to have been lost.

We do hook diathermy skeletonisation and endolooping instead of staples.

Most insured patients (about 50% of the population) will have an attending perform the procedure, with a trainee assisting.

Uninsured patients might have an appropriately experienced trainee with an appropriate level of supervision - eg I did about 20 lap appendixes with various levels of supervision (attending, fellow, senior trainee) before doing one without in-the-OR supervision. Currently the majority of my out of hours uninsured cases are done without in-the-hospital supervision.

Skeptical Scalpel said...

Anon Australia, thank you for the interesting information. I would say what you are experiencing is not common among US surgical residents.

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