Residents in the OR—What’s the Risk?

Orthopaedic educators have long confronted the subtle implication that resident participation in surgical care can contribute to patient harm or even death. While there have been numerous changes in residency education to improve the  supervision and training of residents, the reality is that surgical trainees have to learn how to operate. This fact can leave surgical patients understandably nervous, and many of them heave heard rumors of a “July effect”—a hypothetical increase in surgery-related complications attributed to resident education at the beginning of an academic year. To provide further clarity on this quandary, in the November 21, 2018 issue of The Journal, Casp et al. examine the relationship between complication rates after lower-extremity trauma surgery (for hip fractures, predominantly), the participation and seniority of residents, and when during the academic year the surgery occurred.

The authors used the NSQIP surgical database to examine >1,800 patient outcomes after lower-extremity surgery according to academic-year quarter and the postgraduate year of the most senior resident involved in the case. The analysis revealed two major findings:

1. Overall, there was no “July effect” at the beginning of the academic year in terms of composite complication rates.
2. Cases involving more senior residents were associated with an increased risk of superficial surgical site infection during the first academic quarter.

While the authors were unable to provide a precise reason for the second finding, they hypothesized that it could have been related to more stringent data collection early in the academic year, senior-resident inexperience with newly increased responsibilities, or the warm-temperature time of year in which the infections occurred. Casp et al. emphasize that the database used in the study was not robust in terms of documenting case details such as complexity and the degree of resident autonomy, which makes cause-and-effect conclusions impossible to pinpoint.

Although this large database study does not answer granular questions regarding the appropriate role of residents in orthopaedic surgery, it should stimulate further research in this area. Gradually increasing responsibility is necessary within residency programs so that residents develop the skills and decision-making prowess necessary for them to succeed as attending surgeons. Studies like this help guide future research into the important topic of graduate medical education, and they provide patients with some reassurance that the surgical care they receive is not affected by the time during the academic-calendar year in which they receive it.

Marc Swiontkowski, MD
JBJS Editor-in-Chief