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OBJECTIVE: The volume of cases that residents perform independently have decreased leaving graduating chief residents less prepared for independent practice. Outcomes are not worse when residents are given autonomy with appropriate supervision, however it is unknown if outcomes are worsening with decreasing operative autonomy experience. We hypothesize that resident autonomous cases parallel the improving outcomes in surgical care over time, however, are less complex and on lower acuity patients. DESIGN: Retrospective study utilizing the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. SETTING: Operative cases performed on teaching services within the VASQIP database from July 1, 2004 to September 30, 2019, were included. PARTICIPANTS: All adult patients who underwent a surgical procedure from July 1, 2004, to September 30, 2019, at a VA hospital on a service that included residents were initially included. After inclusions and exclusions, there were 1,346,461 cases. Cases were divided into 3 sequential 5 year eras (ERA 1: 2004-2008 n = 415,614, ERA 2: 2009-2013 n = 478,528, and ERA 3: 2014-2019 n = 452,319). The main exposure of interest was level of resident supervision, coded at the time of procedure as: attending primary surgeon (AP); attending and resident (AR), or resident primary with the attending supervising but not scrubbed (RP). We compared 30 day all-cause mortality, composite morbidity, work relative value unit (wRVU), hospital length of stay, and operative time between each ERA for RP cases, as well as within each ERA for RP cases compared to AR and AP cases. RESULTS: There was a progressive decline in the rate of RP cases in each successive ERA (ERA 1: 58,249 (14.0%) vs ERA 2: 47,891 (10.0%) vs ERA 3: 35,352 (7.8%), p < 0.001). For RP cases, patients were progressively getting older (60 yrs [53-71] vs 63 yrs [54-69] vs 66 yrs [57-72], p < 0.001) and sicker (ASA 3 58.7% vs 62.5% vs 66.2% and ASA 4/5 8.4% vs 9.6% vs10.0%, p < 0.001). Odds of mortality decreased in each ERA compared to the previous (aOR 0.71 [0.62-0.80] ERA 2 vs ERA 1 and 0.82 [0.70-0.97] ERA 3 vs ERA 2) as did morbidity (0.77 [0.73-0.82] ERA 2 vs ERA 1 and 0.72 [0.68-0.77] ERA 3 vs ERA 2). Operative and length of stay also decreased while wRVU stayed unchanged. When comparing RP cases to AP and AR within each ERA, RP cases tended to be on younger and healthier patients with a lower wRVU, particularly compared to AR cases. Mortality and morbidity were no different or better in RP compared to AR and AP. CONCLUSIONS: Despite resident autonomy decreasing, outcomes in cases where they are afforded autonomy are improving over time. This despite RP cases being on sicker and older patients and performing roughly the same complexity of cases. They also continue to perform no worse than cases with higher levels of supervision. Efforts to increase surgical resident operative autonomy are still needed to improve readiness for independent practice.

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IMPORTANCE: Resident operative autonomy has been steadily decreasing. Whether this reduction in autonomy has been associated with changes in patient outcomes is unclear. OBJECTIVE: To assess whether surgical procedures performed by residents without an attending surgeon scrubbed are associated with differences in patient outcomes compared with procedures performed by attending surgeons alone or by residents with the assistance of attending surgeons. DESIGN, SETTING, AND PARTICIPANTS: This retrospective propensity score-matched cohort study analyzed 30-day outcomes among patients who received operations at US Veterans Affairs (VA) medical centers and were recorded within the VA Surgical Quality Improvement Program (VASQIP) database from July 1, 2004, to September 30, 2019. Among 1 797 056 operations recorded in the VASQIP during that period, 1 319 020 were eligible for inclusion. Operations performed by a surgical resident without an attending surgeon scrubbed (resident primary) were propensity score matched on a 1:1 ratio (based on year of procedure and patient age, race, sex, American Society of Anesthesiologists physical status classification, functional status, emergency status, inpatient status, presence of multiple comorbidities, and Current Procedural Terminology code) to operations performed by an attending surgeon only (surgeon primary) and operations performed by a resident with assistance from an attending surgeon (resident plus surgeon). EXPOSURES: Level of resident involvement. MAIN OUTCOMES AND MEASURES: Thirty-day adjusted all-cause mortality. RESULTS: Among 1 319 020 surgical procedures included, 138 750 were performed by residents only, 308 724 were performed by surgeons only, and 871 546 were performed by residents and surgeons. For the 1 319 020 total cases, patients' mean (SD) age was 61.6 (12.9) years; 1 223 051 patients (92.7%) were male; and 212 315 (16.1%) were Black or African American, 63 817 (4.9%) were Hispanic, 830 704 (63.0%) were White, and 212 814 (16.1%) were of other or unknown race and ethnicity. Propensity score matching produced 101 130 pairs of resident-primary and surgeon-primary procedures and 137 749 pairs of resident-primary and resident plus surgeon procedures. Patient all-cause mortality and morbidity were no different among those who received surgeon-primary procedures (mortality: odds ratio [OR], 1.03 [95% CI, 0.95-1.12]; morbidity: OR, 1.01 [95% CI, 0.97-1.05]) vs resident plus surgeon procedures (mortality: OR, 1.03 [95% CI, 0.97-1.11]; all-cause morbidity: OR, 0.97 [95% CI, 0.95-1.00]). Resident-primary procedures had longer operative times than surgeon-primary procedures (median, 80 minutes [IQR, 50-123 minutes] vs 70 minutes [IQR, 41-114 minutes], respectively; P < .001) but shorter operative times than resident plus surgeon procedures (median, 71 minutes [IQR, 43-113 minutes] vs 73 minutes [IQR, 45-115 minutes]; P < .001). Hospital length of stay was unchanged among resident-primary vs surgeon-primary procedures (median, 4 days [IQR, 2-10 days] vs 4 days [IQR, 2-9 days]; P = .08) and statistically significantly shorter than resident plus surgeon procedures (median, 4 days [IQR, 1-9 days] vs 4 days [IQR, 2-10 days]; P < .001). CONCLUSIONS AND RELEVANCE: In this cohort study, surgical procedures performed by residents alone were not associated with any changes in all-cause mortality or composite morbidity compared with those performed by attending surgeons alone or by residents with the assistance of attending surgeons. Given these findings and the importance of operative autonomy to prepare surgical residents for independent practice, efforts to increase autonomy are both safe and needed.

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OBJECTIVE: Resident operative autonomy has been steadily declining. The reasons are multifactorial and include concerns related to patient safety and operating room efficiency. Simultaneously, faculty have expressed that residents are less prepared for independent practice. We sought to understand the effect of decreasing resident autonomy on patient outcomes and operative duration. DESIGN: Retrospective study utilizing the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. SETTING: Operative cases within the VASQIP database from July 1, 2004-September 30, 2019 were analyzed. PARTICIPANTS: All adult patients who underwent a surgical procedure from July 1, 2004 to September 30, 2019 were analyzed. The subpopulation of patients that underwent a surgical procedure in General Surgery or Peripheral Vascular Surgery were identified based on the code of the specialty surgeon. Within these subgroups, the most frequent cases by current procedural terminology (CPT) code were selected for study inclusion. The principle CPT code of all cases was further coded by level of supervision: attending primary surgeon (AP); attending and resident (AR), or resident primary with the attending supervising but not scrubbed (RP). Baseline demographics, operative variables, and outcomes were compared between groups. RESULTS: The VASQIP database included 698,391 total general/vascular surgery cases. 38,483 (6%) of them were RP cases. Analysis revealed that the top 5 RP cases account for 73% of total RP volume-these include: 1) Hernias (55% total; 33% open inguinal, 13% umbilical, 5% open ventral/incisional, and 4% laparoscopic) 2) cholecystectomy (18%), 3) Amputations (17% total; 10% above knee, 7% below knee), 4) Appendectomy (7%) and 5) Open colectomy (3%). The percentage of cases at teaching hospitals that were RP cases significantly decreased from 15% in 2004 to 5% in 2019 (p < 0.001). RP cases were generally sicker as demonstrated by higher ASA classifications and more likely to be emergent cases. Operative times were also increased with resident involvement, but RP cases were faster than AR cases on average. After adjusting for baseline demographics, case type, and year of procedure, mortality was no different between groups. Complications were higher in the AR group but not in the RP group. CONCLUSIONS: The rate of resident autonomy in routine general surgery cases has decreased by two-thirds over the 15-year study period. Cases performed by residents without an attending surgeon scrubbed were performed faster than cases performed by a resident and attending together and there was no increase in patient morbidity or mortality when residents performed cases independently. The erosion of resident autonomy is not justified based upon operative time or patient outcomes. Efforts to increase surgical resident operative autonomy are needed.

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