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:
- Overall, there was no “July effect” at the beginning of the academic year in terms of composite complication rates.
- 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
While patients are sometimes concerned that resident involvement in their surgical case might lead to untoward outcomes, the article by Neuwirth et al. in the January 17, 2018 edition of JBJS provides data to alleviate some of those fears. The authors used the NSQIP database to evaluate whether resident involvement with the surgical treatment of intertrochanteric hip fractures resulted in increased 30-day mortality or morbidity, compared to similar cases in which a resident did not participate. The study found no differences in either 30-day mortality or severe morbidity between cases that involved a resident and those that did not. However, cases involving residents did have significantly longer operative times, lengths of hospital stay, and times from operation to discharge.
These findings, which are similar to those of studies performed in other orthopaedic subspecialties, provide both relief and unease. Surgical education is built on apprenticeship and increasing autonomy throughout residency, so it is comforting that cases of this fracture type involving residents do not increase patient risks of mortality or severe morbidity. The findings suggest that residents are being appropriately supervised and given responsibilities that are commensurate with their level of training.
However, this study also shows that there is a price to be paid for resident education. Any “extra” time that a patient spends in the operating room or the hospital has associated costs to the health care system. Neuwirth et al. show that cases involving residents had a five times greater incidence of lasting more than 90 minutes and an average operative time that was more than 20 minutes longer, compared to cases not involving residents. If one were to extrapolate those added time-related costs across all intertrochanteric fracture surgeries performed in the US each year, the total added annual costs could be astronomical.
My concern is that as we move further toward value-based care, justifying these resident-training costs will become more challenging. Should resident involvement in a case be stopped after a certain amount of operative time? How close should a resident’s surgical time be to that of an attending surgeon’s by the time of graduation? What is the actual cost of resident training per surgical case? This study prompts these and similar difficult questions.
Education, like most investments, requires both time and money in order to pay dividends. While everyone can agree that it is important to train our future surgeons appropriately, there will likely be increasing pressure to do so in the most cost-efficient manner possible.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media