The State of Surgical Training

Since the beginning of formalized training in surgery, the graduated “see one, do one, teach one” method has been the traditional standard. This paradigm has shifted over time with emphasis on trainees performing a certain number of a procedures independently and satisfactorily.¹ The Accreditation Council for Graduate Medical Education Urology Milestones 2.0 was developed in 2020 for this purpose.² Despite this measure, numerous studies have noted that surgical resident autonomy has been eroding over time.^3–5

Are Urology Residents Operating Autonomously?

The Veterans Affairs (VA) teaching hospitals collectively train the largest number of medical residents in the United States and maintain a robust data collection system on operative cases, thus presenting an ideal data source to answer this question. The VA Surgical Quality Improvement Program was queried for the most common urological procedures between July 1, 2004 and September 30, 2019 using CPT codes. Supervision codes, which are recorded prospectively at the time of surgery and denote the relative level of attending involvement and supervision with the resident, including whether the attending was scrubbed, were analyzed in our study. Anjaria et al reported that compared to all surgical subspecialties, urology affords residents the highest proportion of “resident primary” cases where an attending is supervising but not scrubbed.^4,5 During the study period, the proportion of “resident primary” cases in all specialties had a 62% drop in resident operative autonomy, with urology sustaining a 44% drop in resident autonomy (see figure).⁵

The same group demonstrated that for overall surgical teaching cases in which the residents were afforded autonomy, there were no significant differences in complications or mortality when cases were propensity matched controlling for case and patient demographics.⁶ Kunac et al looked at the top “bread and butter” general surgery cases in which resident were allowed to operate unassisted by the attending and showed that even for routine cases autonomy decreased despite equivalent outcomes when the resident was allowed to do the case independently.⁴

Modeled after the above findings by Kunac et al, we further analyzed urological case data in the same system. The findings from our investigation will be presented at the upcoming AUA 2022 Conference in New Orleans. Specifically, when examining the top 7 most frequently performed urological surgeries in the VA system, the resident was the primary surgeon in only 25.7% of the cases in the evaluated 15-year period. The percentage appeared to be decreasing over time for these common urological procedures as well as for more “niche” procedures such as penile prosthesis surgeries.

Figure. Percentage of surgeries done at academic VA training hospitals performed with resident as primary surgeon over time.⁵

How Do the Patients Fare?

Cases with resident involvement had sicker patients with more cardiovascular, pulmonary and other medical comorbidities, including higher rates of functional impairment, current smoker status, recent angina, diabetes, hypertension, stroke, metastatic cancer and ASA^® (American Society of Anesthesiologists^®) class. Despite these factors, our current investigation demonstrated that there was no significance in comparing 30-day all-cause mortality or composite complication rate between supervision levels. Furthermore, average patient length of stay did not greatly vary between different levels of supervision and the surgical operative times in all cases were largely consistent and with in standard deviation between groups.

Is the Reduction in Surgical Autonomy Warranted?

Urology resident autonomy decreased by nearly half over the 15-year period in the most commonly performed urological procedures. The consequences of declining autonomy have been demonstrated in other studies and are evident in the confidence levels of residency program graduates: a survey in 2019 of 120 U.S. urology residencies found that two-thirds of residents pursuing fellowship training did so to overcome perceived shortcomings of their training.⁷

Factors cited for driving reduction in resident autonomy include billing regulations and patient safety initiatives, which require attendings to be present for key portions of the operation, as well as rewards for reduced operative times, incentivizing attendings to perform more of the operation. The current investigation by our group demonstrated that despite the recorded higher ASA class levels and more comorbidities, the patients fared no worse in cases with higher resident autonomy and had similar length of stay as well as operative times. It is hoped that the findings in this study and future research can serve as a platform for re-assessing the wisdom of decreasing surgical autonomy for our residents and spark discussion at the AUA 2022 New Orleans Conference.