JANUARY 7, 2013
Breaking news! Operations take longer when residents are involved

Yes, you heard it here first. A new study shows that for six common laparoscopic procedures, resident participation resulted in the surgery lasting from 20% to 47% longer.

The six laparoscopic operations were appendectomy, cholecystectomy, gastric bypass, fundoplication, colectomy, and inguinal hernia.

The paper, published this month in the Journal of the American College of Surgeons, culled the frequently mined NSQIP database for information on 89,720 operations. The database receives input from a large number of US hospitals, both teaching and non-teaching.

The key results were as follows:   

All of the time differences are statistically and clinically significant.

Hospital length of stays for all groups did not show important differences. Cases involving residents were associated with significantly more morbidity for all procedures except inguinal herniorrhaphy and fundoplication. The authors feel that the increased morbidity seen was not clinically significant. It isn’t clear upon what they based that feeling. There was no difference in mortality rates for the two groups for any operation.

In no less than four places in the text, the statements similar to the following were made. “The presence of a resident during a surgical procedure is a surrogate marker for a learning environment in which there are likely to be other health care learners at each of the stations in the operating room.” The other health care learners might be anesthesia residents, medical students, nursing students or others.

This is a completely unfounded assumption. For example, in three hospitals I worked in over the years, we had a surgical residency training program with no anesthesia residents and no student nurses. Conversely, it is certainly possible to have no residents but have training programs for student nurses or scrub techs.

The authors rightly point out that the increased operative duration associated with resident training translates into some inefficiencies. A single operating room might not be able to process as many cases as it could when cases are done by attending surgeons. Also, longer cases might cost someone (third-party payer? patient?) more money since OR costs are tallied by the minute.

The paper concludes, “Additional work must be undertaken to identify strategies to optimize operating room efficiency and to develop alternate strategies to prepare participants for the performance of the procedure.”

And what would those “alternate strategies” be? You can pick up beads on a simulator all you want, but it’s not the same as doing an operation. And assuming open surgery is still being done somewhere, there is no simulator for open surgery.

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages 800 page views per day, and he has over 4400 followers on Twitter.

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