- Email: [email protected]
Comparable Operative Times With and Without Surgery Resident Participation
2013 APDS SPRING MEETING
Comparable Operative Times With and Without Surgery Resident Participation John Uecker, MD,*† Kevin Luftman, MD,*† Sadia Ali, MPH,*† and Carlos Brown, MD,*† Department of Surgery, University of Texas Southwestern, Austin, Texas; and †University Medical Center at Brackenridge, Austin, Texas
*
BACKGROUND: Both physicians and patients may perceive that having surgical residents participate in operative procedures may prolong operations and worsen outcomes. We hypothesized that resident participation would prolong operative times and potentially adversely affect postoperative outcomes. OBJECTIVE: To evaluate the effect of general surgery
resident participation in surgical procedures on operative times and postoperative patient outcomes. DESIGN: Retrospective study of general surgery procedures performed during two 1-year time periods, 2007 without residents and 2011 with residents. Procedures included laparoscopic appendectomy and cholecystectomy, thyroidectomy, breast procedure, hernia repair, lower extremity amputation, tunneled venous catheter, and percutaneous endoscopic gastrostomy. The primary outcome was operative time and secondary outcomes included length of stay (LOS) and mortality.
(71 vs 66, p ¼ 0.02). LOS was shorter during the year with resident involvement (2.6 days vs 3.7 days, p ¼ 0.0004) and there was no difference in mortality (0.17% vs 0.35%, p ¼ 0.45). CONCLUSIONS: There is no difference in operative time for common general surgery procedures with or without resident involvement. In addition, resident involvement is associated with a decrease in LOS. This information should be used to change physician and patient negative perceptions regarding resident involvement while performing C 2013 Association surgical procedures. ( J Surg 70:696-699. J of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: operative times, residency, general surgery,
length of stay, RRC, ACGME COMPETENCIES: Patient Care, Practice-Based Learning and Improvement, Systems-Based Practice
SETTING: Academic general surgery residency program. RESULTS: There were 2280 operative procedures per-
formed during the 2 periods: 1150 with resident involvement (RES group) and 1130 without residents (NORES group). The RES and NORES groups were similar for patient age (42 vs 41, p ¼ 0.14) and male gender (46% vs 45%, p ¼ 0.68), and there was no difference in overall operative time (68 min vs 66 min, p ¼ 0.58). More specifically there was no difference in operative time (minutes) for specific procedures including laparoscopic appendectomy (67 vs 71, p ¼ 0.8), thyroidectomy (125 vs 109, p ¼ 0.16), breast procedure (38 vs 26, p ¼ 0.79), hernia repair (61 vs 60, p ¼ 0.74), lower extremity amputation (65 vs 77, p ¼ 0.16), tunneled venous catheter (49 vs 47, p ¼ 0.75), and percutaneous endoscopic gastrostomy (49 vs 46, p ¼ 0.76). However, laparoscopic cholecystectomy took slightly longer in the RES group
Correspondence: Inquiries to Carlos Brown, MD, University Medical Center at Brackenridge, 601 E 15th Street, Austin, TX 78701; e-mail: cvrbrown@ seton.org
696
INTRODUCTION Resident participation in the operating room is an essential aspect of surgical training. Even with advances in surgical simulation, there is no substitute for hands-on teaching in the operating room. Common perception is that having resident participation could come at a cost, from both a patient care and a financial standpoint.1,2 With everincreasing pressures of minimizing cost, we are forced to evaluate the financial effect of surgical teaching. Previous studies have shown that resident participation results in longer operative times.2-4 Whether this is attributed to the residents being technically slower or to time spent teaching intraoperatively is likely case dependent, and could probably be more accredited to the individual resident’s level of training and technical skill. Regardless of cause, however, this increase in operating room time has been associated with a great financial cost, with 1 study purporting an annual national cost increase of more than $50 million.5 Furthermore, with respect to laparoscopic surgery, longer
Journal of Surgical Education & 2013 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.06.011
OR times have come with increased rates of complication,6,7 and with that a further increase in cost and length of stay (LOS) in the hospital. These factors would likely cause any residency program to examine the “resident effect” to look for ways to maximize teaching while also minimize any increase in cost or poor outcomes. Our general surgery program began teaching residents in 2009. The youth of our program presents with a unique opportunity to examine the effect that resident involvement has had at our institution. Our hope was to contribute to the existing research and evaluate our own performance at an early point in our existence. We hypothesized that resident involvement would have a detrimental effect on operative times and postoperative outcomes. The specific aims of this study were to investigate operative times and postoperative outcomes of common general surgery procedures with and without surgical resident involvement.
Patient demographics collected for each procedure included age and gender. The primary outcome was operative time (reported in minutes), whereas secondary outcomes included LOS in the hospital and mortality. Information regarding procedures was obtained from our hospital’s operating room database. The procedures performed in 2011 with residents supervised by attending surgeons (RES group) were compared with the procedures performed in 2007 by attending surgeons (NORES group). The RES and NORES groups were compared by univariate analysis for all variables using the unpaired Student t test or Mann-Whitney rank-sum test for the continuous variables and Pearson Chi-square with Yates correction for categorical variables. Values are reported as mean ± standard deviation or raw percentages and statistical significance was set at p o 0.05. The local Institutional Review Board approved this study.
METHODS
RESULTS
We performed a retrospective study of general surgical procedures performed at our institution, University Medical Center Brackenridge in Austin, Texas. We reviewed procedures performed during 2 periods, 1 in 2007 and the other in 2011. In 2007, we were not involved in graduate medical education and did not have general surgery residents on our surgery services. In 2008, we were accredited by the Accreditation Council for Graduate Medical Education and Surgery Residency Review Committee for a new general surgery residency and began training residents. In 2007, procedures were performed by attending surgeons, whereas in 2011, they were performed by general surgery residents under the supervision of attending surgeons. Procedures reviewed during the 2 periods included appendectomy, cholecystectomy, thyroidectomy, breast procedure, hernia repair (inguinal, umbilical, and incisional), lower extremity amputation, tunneled venous catheter, and percutaneous endoscopic gastrostomy (PEG). The 7 core attending general surgeons were the same for both periods.
There were 2280 procedures performed, including 1150 in the RES group and 1130 in the NORES group. Procedures included appendectomy (n ¼ 437, RES: 224 and NORES: 213), cholecystectomy (n ¼ 862, RES: 419 and NORES: 443), thyroidectomy (n ¼ 78, RES: 45 and NORES: 33), breast procedure (n ¼ 68, RES: 18 and NORES: 50), hernia repair (n ¼ 499, RES: 286 and NORES: 213), lower extremity amputation (n ¼ 32, RES: 16 and NORES: 16), tunneled venous catheter (n ¼ 184, RES: 89 and NORES: 95), and PEG (n ¼ 121, RES: 54 and NORES: 67). When comparing the RES and NORES groups, there was no difference in age in years (42 ± 15 vs 41 ± 16, p ¼ 0.14) or male gender (46% vs 45%, p ¼ 0.68). In addition, when combining all procedures performed, there was no difference in operative time (68 ± 66 vs 66 ± 81, p ¼ 0.58). When comparing the RES and NORES groups for individual procedures, there was no difference in operative times for laparoscopic appendectomy (67 ± 125 vs 71 ± 154, p ¼ 0.80), and the open appendectomy rate
TABLE 1. Operative Times With and Without Surgery Resident Involvement Procedure All surgical procedures Laparoscopic appendectomy Laparoscopic cholecystectomy Hernia repair Inguinal hernia repair Incisional hernia repair Umbilical hernia repair Breast procedure Lower extremity amputation PEG Thyroidectomy Tunneled venous catheter
RES Group (n ¼ 1150) 68 67 71 61 67 107 47 38 65 49 125 49
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
NORES Group (n ¼ 1130)
66 min 125 min 32 min 35 min 35 min 61 min 31 min 15 min 25 min 78 min 53 min 41 min
Journal of Surgical Education Volume 70/Number 6 November/December 2013
66 71 66 60 64 79 47 36 77 46 109 47
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
81 min 154 min 28 min 30 min 29 min 38 min 25 min 22 min 23 min 58 min 40 min 36 min
p Value 0.58 0.80 0.02 0.74 0.74 0.12 0.99 0.79 0.16 0.76 0.16 0.75 697
was actually lower in the RES group (5% vs 11%, p ¼ 0.03). Operative times for laparoscopic cholecystectomy were slightly longer in the RES group (71 ± 32 vs 66 ± 28, p ¼ 0.02), but there was no difference in the rate of open cholecystectomy (6% vs 9%, p ¼ 0.19). There was no difference in operative times for hernia repairs (61 ± 35 vs 60 ± 30, p ¼ 0.74), and in particular, there was no difference for repair of inguinal hernias (67 ± 30 vs 64 ± 29, p ¼ 0.33), umbilical hernias (47 ± 31 vs 47 ± 25, p ¼ 0.99), or incisional hernias (107 ± 61 vs 79 ± 38, p ¼ 0.12). Similarly, there was no difference in operative times for thyroidectomy (125 ± 53 vs 109 ± 40, p ¼ 0.16), breast procedure (38 ± 15 vs 36 ± 22, p ¼ 0.79), lower extremity amputation (65 ± 25 vs 77 ± 23, p ¼ 0.16), tunneled venous catheter (49 ± 41 vs 47 ± 36, p ¼ 0.75), or PEG (49 ± 78 vs 46 ± 58, p ¼ 0.76). Operative times are summarized in Table 1. Patients in the RES group had a shorter LOS in days (2.6 ± 6.6 vs 3.7 ± 8.8, p o 0.001), and there was no difference in mortality (0.17% vs 0.35%, p ¼ 0.45).
DISCUSSION This paper demonstrates that surgical resident participation in patient care can decrease hospital LOS for patients while not increasing operating times significantly. This distinctly contrasts with previous studies that have documented longer operative times when surgical residents are involved.3,4 Additionally, the notion that surgical resident participation does not increase operative times challenges most surgeons perceptions of how resident participation affects patient care. We found no difference in overall operative times and no difference in operative times for 11 of the 12 procedures studied. Interestingly, hospital LOS was a day shorter (2.6 vs 3.7; p o 0.001) when residents were involved. There are several potential explanations for these findings. Regarding LOS, when residents are involved, the patients are typically seen earlier for morning rounds and more frequently. Additionally, when patients are on a “teaching service,” there are more personnel available to enter discharge orders, dictate discharge summaries, write prescriptions, etc. All of these factors combine to facilitate more rapid discharge from the hospital. The explanation for resident participation not affecting operative times may be a bit more complex. In our study, the general surgery residency program at The University of Texas Southwestern, Austin was relatively new, so the cases in which surgical residents were participating primarily involved postgraduate year (PGY-1), PGY-2, and some PGY-3 residents. When operating with junior residents, the attending surgeon would frequently do a larger portion of the case with the junior resident functioning as more of an assistant. As the residents have a more prominent role in the case, the attending is still frequently providing the bulk of surgical 698
exposure to expedite the operation particularly in the first couple of years of training. Additionally, just having another “pair of hands” in the operating room can make things run more efficiently so that operating with a surgical resident and an operating room technician may be faster than operating with a technician alone. This study represents the first study that demonstrates a potential benefit to operating with surgical residents with respect to operating room times and LOS. One of the benefits of this study is that we were able to study the same surgeons at the same institution in essentially the same patient population both with and without residents. One of the limitations of the study is that it is single institution based and has relatively limited numbers of patients. Additionally, the 4-year interval between the data collection of the patient populations could have afforded the attending surgeons time to become more efficient with the various procedures studied, which could have affected the results. Senior residents were underrepresented in the study, which could have affected the results; however, previous studies have shown no difference in operating times when comparing senior and junior surgical residents.3 The implications of this study are substantial for administrators and educators weighing the potential benefits, costs, and liabilities of training surgical residents. Previous studies have calculated staggering costs of increased operating times resulting from teaching surgical residents.4,6 In an era when costs are being scrutinized more than ever, the possibility that a training program may actually save money by decreasing hospital LOS could have significant implications at the local community hospital, the established academic center, and at the highest levels of the federal government. Other potential advantages for an institution involved in training surgical residents include that they are more malleable and adaptable to the ongoing changes and demands on physicians regarding compliance (i.e. Surgical Care Improvement Project). Additionally, the younger generation tends to be more technologically savvy. This combination of characteristics, which can be significantly different than the older generation of surgeons, helps facilitate transitioning to computer physician order entry and electronic medical records in a more seamless fashion. In the current environment, that may result in ongoing financial savings for hospital systems. Further study is warranted to validate the findings in this single-institution analysis. From a systems planning standpoint, the concept that residents could decrease costs and save money for an institution would significantly alter the traditionally held perspectives on how medical education affects the bottom line. These principals are extremely important as we move toward “affordable” healthcare for all. In summary, this study compared operative times with the same group of surgeons at the same institution during 2 separate calendar years; 1 without surgical residents and 1 with surgical residents, after a general surgical residency
Journal of Surgical Education Volume 70/Number 6 November/December 2013
program had begun at the institution. Almost a dozen separate procedures were analyzed, and contrary to our hypothesis, there was no difference in overall operative times when completing the procedures with vs without surgical residents. We did however discover that the LOS was significantly shorter when surgical residents were involved in the patient care. The results of this study may alter how surgeons, educators, administrators, and policy makers view the financial effect of training surgical residents.
3. Papandria D, Rhee D, Abdullah F, et al. Assessing
trainee impact on operative time for common general surgical procedures in ACS-NSQIP. J Surg Educ. 2012;69(2):149-155. 4. Hernandez-Irizarry R, Zendejas B, Farley D, et al.
Impact of resident participation on laparoscopic inguinal hernia repairs: are residents slowing us down? J Surg Educ. 2012;69(6):746-752. 5. Bridges M, Diamond D. The financial impact of
REFERENCES 1. Raval MV, Wang X, Cohen ME, et al. The influence of
resident involvement on surgical outcomes. J Am Coll Surg. 2011;212(5):889-898. 2. Advani V, Ahad S, Gonczy C, Markwell S, Hassan I.
Does resident involvement effect surgical times and complication rates during laparoscopic appendectomy for uncomplicated appendicitis. Am J Surg. 2012;203 (3):347-351.
teaching surgical residents in the operating room. Am J Surg. 1999;177:28-32. 6. Jackson T, Wannares J, Lancaster R, Rattner D, Hutter
M. Does speed matter? the impact of operative time on outcome in laparoscopic surgery. Surg Endosc. 2011;25:2288-2295. 7. Scheer A, Martel G, Moloo H, et al. Laparoscopic colon
surgery: does operative time matter? Dis Colon Rectum. 2009;52(10):1746-1752.
Journal of Surgical Education Volume 70/Number 6 November/December 2013
699
Comparable Operative Times With and Without Surgery Resident Participation John Uecker, MD,*† Kevin Luftman, MD,*† Sadia Ali, MPH,*† and Carlos Brown, MD,*† Department of Surgery, University of Texas Southwestern, Austin, Texas; and †University Medical Center at Brackenridge, Austin, Texas
*
BACKGROUND: Both physicians and patients may perceive that having surgical residents participate in operative procedures may prolong operations and worsen outcomes. We hypothesized that resident participation would prolong operative times and potentially adversely affect postoperative outcomes. OBJECTIVE: To evaluate the effect of general surgery
resident participation in surgical procedures on operative times and postoperative patient outcomes. DESIGN: Retrospective study of general surgery procedures performed during two 1-year time periods, 2007 without residents and 2011 with residents. Procedures included laparoscopic appendectomy and cholecystectomy, thyroidectomy, breast procedure, hernia repair, lower extremity amputation, tunneled venous catheter, and percutaneous endoscopic gastrostomy. The primary outcome was operative time and secondary outcomes included length of stay (LOS) and mortality.
(71 vs 66, p ¼ 0.02). LOS was shorter during the year with resident involvement (2.6 days vs 3.7 days, p ¼ 0.0004) and there was no difference in mortality (0.17% vs 0.35%, p ¼ 0.45). CONCLUSIONS: There is no difference in operative time for common general surgery procedures with or without resident involvement. In addition, resident involvement is associated with a decrease in LOS. This information should be used to change physician and patient negative perceptions regarding resident involvement while performing C 2013 Association surgical procedures. ( J Surg 70:696-699. J of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: operative times, residency, general surgery,
length of stay, RRC, ACGME COMPETENCIES: Patient Care, Practice-Based Learning and Improvement, Systems-Based Practice
SETTING: Academic general surgery residency program. RESULTS: There were 2280 operative procedures per-
formed during the 2 periods: 1150 with resident involvement (RES group) and 1130 without residents (NORES group). The RES and NORES groups were similar for patient age (42 vs 41, p ¼ 0.14) and male gender (46% vs 45%, p ¼ 0.68), and there was no difference in overall operative time (68 min vs 66 min, p ¼ 0.58). More specifically there was no difference in operative time (minutes) for specific procedures including laparoscopic appendectomy (67 vs 71, p ¼ 0.8), thyroidectomy (125 vs 109, p ¼ 0.16), breast procedure (38 vs 26, p ¼ 0.79), hernia repair (61 vs 60, p ¼ 0.74), lower extremity amputation (65 vs 77, p ¼ 0.16), tunneled venous catheter (49 vs 47, p ¼ 0.75), and percutaneous endoscopic gastrostomy (49 vs 46, p ¼ 0.76). However, laparoscopic cholecystectomy took slightly longer in the RES group
Correspondence: Inquiries to Carlos Brown, MD, University Medical Center at Brackenridge, 601 E 15th Street, Austin, TX 78701; e-mail: cvrbrown@ seton.org
696
INTRODUCTION Resident participation in the operating room is an essential aspect of surgical training. Even with advances in surgical simulation, there is no substitute for hands-on teaching in the operating room. Common perception is that having resident participation could come at a cost, from both a patient care and a financial standpoint.1,2 With everincreasing pressures of minimizing cost, we are forced to evaluate the financial effect of surgical teaching. Previous studies have shown that resident participation results in longer operative times.2-4 Whether this is attributed to the residents being technically slower or to time spent teaching intraoperatively is likely case dependent, and could probably be more accredited to the individual resident’s level of training and technical skill. Regardless of cause, however, this increase in operating room time has been associated with a great financial cost, with 1 study purporting an annual national cost increase of more than $50 million.5 Furthermore, with respect to laparoscopic surgery, longer
Journal of Surgical Education & 2013 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.06.011
OR times have come with increased rates of complication,6,7 and with that a further increase in cost and length of stay (LOS) in the hospital. These factors would likely cause any residency program to examine the “resident effect” to look for ways to maximize teaching while also minimize any increase in cost or poor outcomes. Our general surgery program began teaching residents in 2009. The youth of our program presents with a unique opportunity to examine the effect that resident involvement has had at our institution. Our hope was to contribute to the existing research and evaluate our own performance at an early point in our existence. We hypothesized that resident involvement would have a detrimental effect on operative times and postoperative outcomes. The specific aims of this study were to investigate operative times and postoperative outcomes of common general surgery procedures with and without surgical resident involvement.
Patient demographics collected for each procedure included age and gender. The primary outcome was operative time (reported in minutes), whereas secondary outcomes included LOS in the hospital and mortality. Information regarding procedures was obtained from our hospital’s operating room database. The procedures performed in 2011 with residents supervised by attending surgeons (RES group) were compared with the procedures performed in 2007 by attending surgeons (NORES group). The RES and NORES groups were compared by univariate analysis for all variables using the unpaired Student t test or Mann-Whitney rank-sum test for the continuous variables and Pearson Chi-square with Yates correction for categorical variables. Values are reported as mean ± standard deviation or raw percentages and statistical significance was set at p o 0.05. The local Institutional Review Board approved this study.
METHODS
RESULTS
We performed a retrospective study of general surgical procedures performed at our institution, University Medical Center Brackenridge in Austin, Texas. We reviewed procedures performed during 2 periods, 1 in 2007 and the other in 2011. In 2007, we were not involved in graduate medical education and did not have general surgery residents on our surgery services. In 2008, we were accredited by the Accreditation Council for Graduate Medical Education and Surgery Residency Review Committee for a new general surgery residency and began training residents. In 2007, procedures were performed by attending surgeons, whereas in 2011, they were performed by general surgery residents under the supervision of attending surgeons. Procedures reviewed during the 2 periods included appendectomy, cholecystectomy, thyroidectomy, breast procedure, hernia repair (inguinal, umbilical, and incisional), lower extremity amputation, tunneled venous catheter, and percutaneous endoscopic gastrostomy (PEG). The 7 core attending general surgeons were the same for both periods.
There were 2280 procedures performed, including 1150 in the RES group and 1130 in the NORES group. Procedures included appendectomy (n ¼ 437, RES: 224 and NORES: 213), cholecystectomy (n ¼ 862, RES: 419 and NORES: 443), thyroidectomy (n ¼ 78, RES: 45 and NORES: 33), breast procedure (n ¼ 68, RES: 18 and NORES: 50), hernia repair (n ¼ 499, RES: 286 and NORES: 213), lower extremity amputation (n ¼ 32, RES: 16 and NORES: 16), tunneled venous catheter (n ¼ 184, RES: 89 and NORES: 95), and PEG (n ¼ 121, RES: 54 and NORES: 67). When comparing the RES and NORES groups, there was no difference in age in years (42 ± 15 vs 41 ± 16, p ¼ 0.14) or male gender (46% vs 45%, p ¼ 0.68). In addition, when combining all procedures performed, there was no difference in operative time (68 ± 66 vs 66 ± 81, p ¼ 0.58). When comparing the RES and NORES groups for individual procedures, there was no difference in operative times for laparoscopic appendectomy (67 ± 125 vs 71 ± 154, p ¼ 0.80), and the open appendectomy rate
TABLE 1. Operative Times With and Without Surgery Resident Involvement Procedure All surgical procedures Laparoscopic appendectomy Laparoscopic cholecystectomy Hernia repair Inguinal hernia repair Incisional hernia repair Umbilical hernia repair Breast procedure Lower extremity amputation PEG Thyroidectomy Tunneled venous catheter
RES Group (n ¼ 1150) 68 67 71 61 67 107 47 38 65 49 125 49
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
NORES Group (n ¼ 1130)
66 min 125 min 32 min 35 min 35 min 61 min 31 min 15 min 25 min 78 min 53 min 41 min
Journal of Surgical Education Volume 70/Number 6 November/December 2013
66 71 66 60 64 79 47 36 77 46 109 47
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
81 min 154 min 28 min 30 min 29 min 38 min 25 min 22 min 23 min 58 min 40 min 36 min
p Value 0.58 0.80 0.02 0.74 0.74 0.12 0.99 0.79 0.16 0.76 0.16 0.75 697
was actually lower in the RES group (5% vs 11%, p ¼ 0.03). Operative times for laparoscopic cholecystectomy were slightly longer in the RES group (71 ± 32 vs 66 ± 28, p ¼ 0.02), but there was no difference in the rate of open cholecystectomy (6% vs 9%, p ¼ 0.19). There was no difference in operative times for hernia repairs (61 ± 35 vs 60 ± 30, p ¼ 0.74), and in particular, there was no difference for repair of inguinal hernias (67 ± 30 vs 64 ± 29, p ¼ 0.33), umbilical hernias (47 ± 31 vs 47 ± 25, p ¼ 0.99), or incisional hernias (107 ± 61 vs 79 ± 38, p ¼ 0.12). Similarly, there was no difference in operative times for thyroidectomy (125 ± 53 vs 109 ± 40, p ¼ 0.16), breast procedure (38 ± 15 vs 36 ± 22, p ¼ 0.79), lower extremity amputation (65 ± 25 vs 77 ± 23, p ¼ 0.16), tunneled venous catheter (49 ± 41 vs 47 ± 36, p ¼ 0.75), or PEG (49 ± 78 vs 46 ± 58, p ¼ 0.76). Operative times are summarized in Table 1. Patients in the RES group had a shorter LOS in days (2.6 ± 6.6 vs 3.7 ± 8.8, p o 0.001), and there was no difference in mortality (0.17% vs 0.35%, p ¼ 0.45).
DISCUSSION This paper demonstrates that surgical resident participation in patient care can decrease hospital LOS for patients while not increasing operating times significantly. This distinctly contrasts with previous studies that have documented longer operative times when surgical residents are involved.3,4 Additionally, the notion that surgical resident participation does not increase operative times challenges most surgeons perceptions of how resident participation affects patient care. We found no difference in overall operative times and no difference in operative times for 11 of the 12 procedures studied. Interestingly, hospital LOS was a day shorter (2.6 vs 3.7; p o 0.001) when residents were involved. There are several potential explanations for these findings. Regarding LOS, when residents are involved, the patients are typically seen earlier for morning rounds and more frequently. Additionally, when patients are on a “teaching service,” there are more personnel available to enter discharge orders, dictate discharge summaries, write prescriptions, etc. All of these factors combine to facilitate more rapid discharge from the hospital. The explanation for resident participation not affecting operative times may be a bit more complex. In our study, the general surgery residency program at The University of Texas Southwestern, Austin was relatively new, so the cases in which surgical residents were participating primarily involved postgraduate year (PGY-1), PGY-2, and some PGY-3 residents. When operating with junior residents, the attending surgeon would frequently do a larger portion of the case with the junior resident functioning as more of an assistant. As the residents have a more prominent role in the case, the attending is still frequently providing the bulk of surgical 698
exposure to expedite the operation particularly in the first couple of years of training. Additionally, just having another “pair of hands” in the operating room can make things run more efficiently so that operating with a surgical resident and an operating room technician may be faster than operating with a technician alone. This study represents the first study that demonstrates a potential benefit to operating with surgical residents with respect to operating room times and LOS. One of the benefits of this study is that we were able to study the same surgeons at the same institution in essentially the same patient population both with and without residents. One of the limitations of the study is that it is single institution based and has relatively limited numbers of patients. Additionally, the 4-year interval between the data collection of the patient populations could have afforded the attending surgeons time to become more efficient with the various procedures studied, which could have affected the results. Senior residents were underrepresented in the study, which could have affected the results; however, previous studies have shown no difference in operating times when comparing senior and junior surgical residents.3 The implications of this study are substantial for administrators and educators weighing the potential benefits, costs, and liabilities of training surgical residents. Previous studies have calculated staggering costs of increased operating times resulting from teaching surgical residents.4,6 In an era when costs are being scrutinized more than ever, the possibility that a training program may actually save money by decreasing hospital LOS could have significant implications at the local community hospital, the established academic center, and at the highest levels of the federal government. Other potential advantages for an institution involved in training surgical residents include that they are more malleable and adaptable to the ongoing changes and demands on physicians regarding compliance (i.e. Surgical Care Improvement Project). Additionally, the younger generation tends to be more technologically savvy. This combination of characteristics, which can be significantly different than the older generation of surgeons, helps facilitate transitioning to computer physician order entry and electronic medical records in a more seamless fashion. In the current environment, that may result in ongoing financial savings for hospital systems. Further study is warranted to validate the findings in this single-institution analysis. From a systems planning standpoint, the concept that residents could decrease costs and save money for an institution would significantly alter the traditionally held perspectives on how medical education affects the bottom line. These principals are extremely important as we move toward “affordable” healthcare for all. In summary, this study compared operative times with the same group of surgeons at the same institution during 2 separate calendar years; 1 without surgical residents and 1 with surgical residents, after a general surgical residency
Journal of Surgical Education Volume 70/Number 6 November/December 2013
program had begun at the institution. Almost a dozen separate procedures were analyzed, and contrary to our hypothesis, there was no difference in overall operative times when completing the procedures with vs without surgical residents. We did however discover that the LOS was significantly shorter when surgical residents were involved in the patient care. The results of this study may alter how surgeons, educators, administrators, and policy makers view the financial effect of training surgical residents.
3. Papandria D, Rhee D, Abdullah F, et al. Assessing
trainee impact on operative time for common general surgical procedures in ACS-NSQIP. J Surg Educ. 2012;69(2):149-155. 4. Hernandez-Irizarry R, Zendejas B, Farley D, et al.
Impact of resident participation on laparoscopic inguinal hernia repairs: are residents slowing us down? J Surg Educ. 2012;69(6):746-752. 5. Bridges M, Diamond D. The financial impact of
REFERENCES 1. Raval MV, Wang X, Cohen ME, et al. The influence of
resident involvement on surgical outcomes. J Am Coll Surg. 2011;212(5):889-898. 2. Advani V, Ahad S, Gonczy C, Markwell S, Hassan I.
Does resident involvement effect surgical times and complication rates during laparoscopic appendectomy for uncomplicated appendicitis. Am J Surg. 2012;203 (3):347-351.
teaching surgical residents in the operating room. Am J Surg. 1999;177:28-32. 6. Jackson T, Wannares J, Lancaster R, Rattner D, Hutter
M. Does speed matter? the impact of operative time on outcome in laparoscopic surgery. Surg Endosc. 2011;25:2288-2295. 7. Scheer A, Martel G, Moloo H, et al. Laparoscopic colon
surgery: does operative time matter? Dis Colon Rectum. 2009;52(10):1746-1752.
Journal of Surgical Education Volume 70/Number 6 November/December 2013
699