By Rebecca Williams-Karnesky, MD, PhD

“I’m going to time you out; then I’m going next door to start the next case. I’ll be back to check on you; let me know if you need anything.” 

Those were the words my attending said to me before he left me to operate alone—totally alone—for the first time. I was doing an elective inguinal hernia repair, an operation I’d done a fair number of times before. But this time it felt different. There was no security blanket: no attending to watch over my shoulder, no chief to guide me through, no junior to act as a second pair of eyes, as inexperienced as they might be. It was just me and the scrub technician as my first assist. “Do you want a scalpel?” she asked. “Right,” I replied, taking the blade. “Incision.” I called out, loud enough so the anesthesiologist could hear. I was the surgeon.

The Autonomy Crisis in Surgical Residency

Perhaps the single most important issue facing young surgeons today is readiness for independent practice at the completion of residency. Many young surgeons lack confidence in their skills, even if they are highly qualified. One survey of 676 graduating chief residents from 55 general surgery training programs found that 23% of respondents did not feel adequately prepared to practice as a general surgeon.¹

Residents aren’t the only ones who feel they aren’t ready for independence. A 2013 survey of surgical fellowship directors revealed that this group believed their incoming fellows were woefully unprepared for independent practice. Strikingly, 30% of responding fellowship directors believed incoming fellows could not perform a laparoscopic cholecystectomy independently, and 66% thought that incoming fellows were unable to operate unsupervised for 30 minutes during a major surgical procedure.²

Duty Hours Aren’t to Blame 

In 2003, in response to widely publicized concerns about resident supervision and medical errors,³ the Accreditation Council for Graduate Medical Education (ACGME) implemented the common standards for duty hours for residents, limiting surgery residents to 80 hours per week of work. Since that time, the argument has been made that because duty hours limit the amount of time residents spend in the hospital, they have led to a decrease in operative case volumes resulting in decreased resident autonomy.

However, around the time duty hours limits were being enforced by the ACGME, Medicare and Medicaid policies restricting billing for procedures performed by resident physicians also were enacted.⁴ A 2002 mandate by the Center for Medicare & Medicaid Services (CMS) required attendings to be present for “critical” portions of a case in order to be able to bill for them.⁴ This new requirement added to 1997 legislation mandating that physicians billing in a teaching setting involving resident care meet specific criteria, including “personally performing” the service in order to qualify for reimbursement.⁵ Although the intent of these legislative policies was to increase faculty supervision of residents in order to decrease rates of medical errors, the impact has been a decrease in autonomy for surgical residents.

This phenomenon is unintentionally documented in one study looking at the impact of duty hour restrictions on surgery resident case volumes.⁶ Although the total number of major cases performed by general surgery residents decreased by only 2.3% post–duty hour restrictions, teaching assistant cases—defined as cases in which a senior-level resident takes a junior resident through an operation—declined by 66%.⁶ Data from this study show that the decrease in the number of teaching assistant cases began in the late 1990s, before duty hours were enacted and around the time the CMS billing requirements for resident services were changed.

Potential Models for Billing for Resident-Led Procedures

Despite high-profile stories in the popular press depicting resident autonomy as a detriment to patient safety,^7,8 there is increasing evidence that operations in which residents are allowed to function autonomously are safe and do not result in higher rates of complications than those in which an attending is present for the entire procedure.^9-11 A 2017 study comparing outcomes of 1,649 appendectomies performed by unsupervised general surgery residents (n=548) versus those supervised by an attending surgeon (n=1,101) found no significant difference in overall postoperative complications or hospital length of stay.¹⁰

In order to successfully enact billing for resident-led services, it is important to begin by selecting appropriate procedures. In the era of milestones,¹² entrustable professional activities¹³ and robust instruments for evaluating the technical skills of residents,^14,15 this is increasingly possible. One example might be allowing residents in their third year and above to bill for minor procedures in a resident-run clinic, a paradigm that has already been shown to be feasible and safe for patient care.¹⁶ Another example might be allowing fifth-year residents who have met their ACGME level 4 milestones¹² and have been documented to have obtained “supervision only” status on intraoperative performance evaluations¹⁵ to bill for specific core operations, such as cholecystectomies, inguinal hernia repairs, appendectomies and ventral hernia repairs. Models like the “chief resident service” at Gundersen Health System, in La Crosse, Wis., have successfully approximated this paradigm.¹⁷

Resident Billing Will Increase Educational Opportunities

Allowing residents to bill for specific procedures would have additional educational benefits. If residents were allowed to bill for procedures, they would also be required to dictate the operative report, a critical skill for functioning as an independent surgeon. At some institutions, residents are not allowed to dictate operative reports due to billing concerns. I recently saw an informal poll on Twitter, started by a general surgery resident who asked: “How often do/did you dictate in surgical residency?” Of 133 respondents, only 25.6% said always, 36.8% said often, 21.1% said rarely, and a shocking 16.5% said “never.”¹⁸

Resident-led billing would also incentivize institutions to educate residents about the complex coding structures used for reimbursement, a skill that is frequently lacking in residency training.^19-21 The need for this type of education is evidenced by the creation of “transitional years,” like the American College of Surgeons Mastery in General Surgery Program.²² In addition to being designed to “build autonomy, decision-making, and clinical skills,” this programs emphasizes that trainees will receive education about billing and medical liability.²²

Litigation is also a major driver of reduced resident autonomy, especially when attending physicians are held vicariously liable for negligence on the part of trainees.²³ Allowing residents to bill for procedures would need to be coupled with changes in medicolegal liability that supports resident autonomy.²⁴ These efforts would necessitate engagement with agencies such as CMS and require encouraging third-party payors to reimburse for resident-led services.

Moving Toward Resident Autonomy

I feel fortunate to be training in a residency program in which I have experienced real autonomy. Experiences like my first solo inguinal hernia repair have allowed me to understand what it is like to operate independently. But talking to residents from other programs and reading the literature, I know this is the exception and not the rule. Allowing residents to bill for procedures has the potential to drastically increase resident autonomy and help ensure that young surgeons are better prepared for independent practice.

References

1. J Am Coll Surg. 2013;216(4):764-771; discussion 771-773. doi: 10.1016/j.jamcollsurg.2012.12.045

2. Ann Surg. 2013;258(3):440-449. doi: 10.1097/SLA.0b013e3182a191ca

3. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. National Academies Press; 2000. www.ncbi.nlm.nih.gov/books/NBK225182/. Accessed May 8, 2020.

4. Medicare Carriers Manual. Part 3 - claims process. www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1780B3.pdf. Accessed May 8, 2020.

5. Medicare Claims Processing Manual. www.cms.gov/files/document/medicare-claims-processing-manual-chapter-12. Accessed May 8, 2020.

6. J Am Coll Surg. 2008;206(5):804-811; discussion 811-813. doi: 10.1016/j.jamcollsurg.2007.12.055

7. The Boston Globe. https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/. Published 2015. Accessed May 8, 2020.

8. The Chicago Tribune. www.chicagotribune.com/news/ct-xpm-2012-09-23-ct-met-surgeon-switch-20120923-story.html. Published September 23, 2012. Accessed May 8, 2020.

9. J Surg Educ. 2013;70(6):796-799. doi: 10.1016/j.jsurg.2013.09.011

10. JAMA Surg. 2017;152(7):679-685. doi: 10.1001/jamasurg.2017.0578

11. JAMA. 2019;321(8):762-772. doi: 10.1001/jama.2019.0711

12. ACGME. ACGME Surgical Miletsones. January 2019. www.acgme.org/Portals/0/PDFs/Milestones/SurgeryMilestones2.0.pdf?ver=2019-05-29-124604-347. Accessed May 8, 2020.

13. Am J Surg. December 2018. doi: 10.1016/j.amjsurg.2018.12.056

14. Ann Surg. 2017;266(4):582-594. doi: 10.1097/SLA.0000000000002414

15. J Surg Educ. 2014;71(6):e64-e72. doi: 10.1016/j.jsurg.2014.05.002

16. J Surg Educ. 2016;73(6):e142-e149. doi: 10.1016/j.jsurg.2016.08.016

17. J Surg Educ. 2018;75(4):888-894. doi: 10.1016/j.jsurg.2017.12.012

18. Twitter.com. twitter.com/cchildersmd/status/1207496530116005888. Published December 18, 2019. Accessed May 8, 2020.

19. J Surg Educ. 2016;73(6):e59-e63. doi: 10.1016/j.jsurg.2016.07.017

20. Am J Surg. 2007;194(2):263-267. doi: 10.1016/j.amjsurg.2006.11.031

21. Surgery. 2015;158(3):773-776. doi: 10.1016/j.surg.2015.02.028

22. American College Surgeons. Mastery in General Surgery Program. 2019. www.facs.org/education/program/masterygs. Accessed May 8, 2020.

23. JAMA. 2004;292(9):1051-1056. doi: 10.1001/jama.292.9.1051

24. The Bulletin. August 2018. http://bulletin.facs.org/2018/08/the-autonomy-crisis-a-call-to-action-for-resident-advocacy/. Accessed May 8, 2020.

—Dr. Williams-Karnesky is a surgical education research fellow, Department of General Surgery, University of New Mexico Hospital, Albuquerque.