Resident Learning and Surgical Risk: How Trainee Participation Affects Patient Safety

Background: Surgical residents need to operate to become competent surgeons. With a desire to reduce patient complications and standards being set appropriately high for quality of care, surgical supervision has increased over time leading to a proportional decrease in autonomy. Concordantly, graduating residents are increasingly perceived as being unready for independent practice: by themselves, their attendings, and often by patients. Objectives: The objective of this thesis is to assess how risk is currently evaluated, and how resident involvement in a surgical case affects that risk. Methods: The thesis consists of three studies. The first, a systematic review, summarizes perioperative risk prediction models, It evaluates the prediction accuracy of risk prediction models using intraoperative and educational variables differ from those using preoperative variables alone. The second study is a retrospective cohort study correlating resident training level with perioperative morbidity and mortality. The final study explores the relationship of resident autonomy to intraoperative events in recorded operations. Results: We found that few modifiable intraoperative factors are used to predict surgical morbidity and mortality. Team composition and resident involvement were not used in any multivariate risk prediction strategies. After adjusting for patient- and procedural covariates, patient outcomes were not adversely affected by the training level of the assist. Finally, we demonstrated that operative skill and step complexity appear to be related to intraoperative adverse events. Resident autonomy, however, was not correlated with intraoperative events. This tentatively suggests that the degree of autonomy residents are given appears to be safe. Conclusions: Through this work, we have demonstrated that resident involvement and educational metrics are under utilized in estimating patient risk and optimizing surgical teams. We have begun to fill this gap in the literature by demonstrating that resident involvement in surgical procedures is not inherently related to poorer safety outcomes. We hope that this work serves as a basis for patient reassurance: that residents have been getting appropriate supervision in surgery and that education does not compromise surgical quality. Going forward, we aim to continue this work in evidence-based surgical education to inform how best to safely develop the next generation of trainees from novice to surgical mastery.

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