Commentary

Resident, fellow involvement may not affect orthopedic outcomes

Anthony A. Romeo, MD
Anthony A. Romeo

The real-time, intraoperative teaching of surgical trainees, including residents and fellows, is critical to training the next generation of orthopedic surgeons. Yet, one of the most common questions patients ask before surgery, especially in teaching hospitals, is whether a resident will be involved in their case. While many patients understand surgical training must include hands-on experience, no patient wants the “new” surgeon or “surgeon in training” working on them.

Questions remain on the best method to train the next generation of surgeons while satisfying the needs and expectations of patients. Most patients, and even many surgeons in practice, are not familiar with the risks and benefits of having surgeons-in-training involved in patient care.

Published literature

Several studies have been published during the past decade analyzing surgical outcomes of orthopedic patients with vs. without the involvement of surgeons-in-training in their care. Pugely and colleagues used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) dataset to evaluate the impact of resident involvement in surgical cases on short-term morbidity, mortality, operating time, hospital length of stay and reoperation rate among patients who underwent 66,817 cases; including total joint arthroplasty, revision joint arthroplasty, arthroscopy, lower extremity trauma and spinal fusions, between 2005 and 2011, . They found resident involvement was not associated with increased mortality, however, it was associated with higher minor morbidity in TJA, lower extremity trauma and spinal fusion cases. Operative time was also significantly greater for all types of procedures in cases involving residents. Remarkably, the level of resident training was not found to have any consistent impact on surgical outcomes.

Neuwirth and colleagues utilized the same NSQIP database to evaluate the impact of resident involvement on surgical outcomes of patients who underwent surgical fixation of intertrochanteric hip fractures. The authors found no differences in 30-day mortality or serious morbidity in cases with vs. without resident involvement. Notably, the authors found resident involvement was associated with longer operative time and length of stay, results like those found by Pugely and colleagues.

Gross and colleagues analyzed the 2005 to 2015 NSQIP database assessing the impact of resident involvement on common foot and ankle operations. The authors found resident cases did not correlate with 30-day mortality, 30-day total morbidity or 30-day surgical complications but were associated with increased medical complications compared to non-resident cases. Residents were more likely to be involved in surgical cases involving more complicated patients.

Cvetanovich and colleagues analyzed the NSQIP database for patients who underwent primary total shoulder arthroplasty with vs. without resident involvement. The authors found resident involvement in shoulder arthroplasty procedures was not associated with higher 30-day complication rates, and operative time and hospital length of stay were decreased in cases in which a resident was involved compared to cases in which no resident was involved. Haughom and colleagues found similar results for patients who underwent total hip arthroplasty (THA) in the NSQIP database, with no increased rates of postoperative complications in patients who underwent surgery with resident involvement.

When pooling the best available data on large volumes of orthopedic surgeries performed in the U.S., resident involvement in these surgeries has not been associated with high mortality or morbidity. However, depending on the procedure, resident involvement may be associated with increased operative times, short-term complications and hospital length of stay. This information can be used to counsel patients on the real and perceived risks of having residents involved in their surgical care. It also can be used to improve the level of supervision and guidance provided by attending surgeons.

Rachel M. Frank, MD
Rachel M. Frank

‘July effect’

Another often discussed topic is the so-called “July effect.” As the first day of residency occurs on July 1 each year, the term refers to a time in the hospital in which patient morbidity and mortality are perceived to be higher than other times of the year due to the new physicians.

Several studies have disproven the July effect. Rao and colleagues used the NSQIP database to determine the outcomes of patients who underwent shoulder arthroplasty during the first academic quarter of the year and found no evidence for a July effect with respect to the rate of adverse events, including serious adverse events, in cases involving a resident or fellow. Bohl and colleagues utilized this same database to assess THA and total knee arthroplasty cases in the first academic quartile, and similarly found no impact of adverse events in cases involving residents. In another study, they found the rate of adverse events among patients who underwent spine surgery during the first quarter was higher in cases involving residents, compared with cases without resident involvement. However, this change was consistent throughout all 4 academic quarters and thus no July effect was found.

Top priority

Practicing surgeons developed their surgical skills and medical decision-making abilities while training as a resident and fellow. Without this process, there would be no mechanism for training the next generation of orthopedic surgeons. The question of whether the involvement of surgical trainees negatively impacts patient care is a reasonable question for patients to ask.

The data suggest resident involvement in a wide variety of orthopedic surgeries has no significant impact on patient morbidity and mortality. To a large degree, both the surgeons-in-training and their supervising attending surgeons should be commended for the results that suggest patient care and outcomes remain the priority of training programs. The ability and patience to train future orthopedic surgeons while maintaining high standards of patient care speaks to the dedication and skill of academic surgeons responsible for educating the next generation of orthopedic surgeons.

Disclosures: Romeo reports he receives royalties, is on the speaker’s bureau and a consultant for Arthrex; does contracted research for Arthrex and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex, Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed. Frank reports no relevant financial disclosures.

Anthony A. Romeo, MD
Anthony A. Romeo

The real-time, intraoperative teaching of surgical trainees, including residents and fellows, is critical to training the next generation of orthopedic surgeons. Yet, one of the most common questions patients ask before surgery, especially in teaching hospitals, is whether a resident will be involved in their case. While many patients understand surgical training must include hands-on experience, no patient wants the “new” surgeon or “surgeon in training” working on them.

Questions remain on the best method to train the next generation of surgeons while satisfying the needs and expectations of patients. Most patients, and even many surgeons in practice, are not familiar with the risks and benefits of having surgeons-in-training involved in patient care.

Published literature

Several studies have been published during the past decade analyzing surgical outcomes of orthopedic patients with vs. without the involvement of surgeons-in-training in their care. Pugely and colleagues used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) dataset to evaluate the impact of resident involvement in surgical cases on short-term morbidity, mortality, operating time, hospital length of stay and reoperation rate among patients who underwent 66,817 cases; including total joint arthroplasty, revision joint arthroplasty, arthroscopy, lower extremity trauma and spinal fusions, between 2005 and 2011, . They found resident involvement was not associated with increased mortality, however, it was associated with higher minor morbidity in TJA, lower extremity trauma and spinal fusion cases. Operative time was also significantly greater for all types of procedures in cases involving residents. Remarkably, the level of resident training was not found to have any consistent impact on surgical outcomes.

Neuwirth and colleagues utilized the same NSQIP database to evaluate the impact of resident involvement on surgical outcomes of patients who underwent surgical fixation of intertrochanteric hip fractures. The authors found no differences in 30-day mortality or serious morbidity in cases with vs. without resident involvement. Notably, the authors found resident involvement was associated with longer operative time and length of stay, results like those found by Pugely and colleagues.

Gross and colleagues analyzed the 2005 to 2015 NSQIP database assessing the impact of resident involvement on common foot and ankle operations. The authors found resident cases did not correlate with 30-day mortality, 30-day total morbidity or 30-day surgical complications but were associated with increased medical complications compared to non-resident cases. Residents were more likely to be involved in surgical cases involving more complicated patients.

Cvetanovich and colleagues analyzed the NSQIP database for patients who underwent primary total shoulder arthroplasty with vs. without resident involvement. The authors found resident involvement in shoulder arthroplasty procedures was not associated with higher 30-day complication rates, and operative time and hospital length of stay were decreased in cases in which a resident was involved compared to cases in which no resident was involved. Haughom and colleagues found similar results for patients who underwent total hip arthroplasty (THA) in the NSQIP database, with no increased rates of postoperative complications in patients who underwent surgery with resident involvement.

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When pooling the best available data on large volumes of orthopedic surgeries performed in the U.S., resident involvement in these surgeries has not been associated with high mortality or morbidity. However, depending on the procedure, resident involvement may be associated with increased operative times, short-term complications and hospital length of stay. This information can be used to counsel patients on the real and perceived risks of having residents involved in their surgical care. It also can be used to improve the level of supervision and guidance provided by attending surgeons.

Rachel M. Frank, MD
Rachel M. Frank

‘July effect’

Another often discussed topic is the so-called “July effect.” As the first day of residency occurs on July 1 each year, the term refers to a time in the hospital in which patient morbidity and mortality are perceived to be higher than other times of the year due to the new physicians.

Several studies have disproven the July effect. Rao and colleagues used the NSQIP database to determine the outcomes of patients who underwent shoulder arthroplasty during the first academic quarter of the year and found no evidence for a July effect with respect to the rate of adverse events, including serious adverse events, in cases involving a resident or fellow. Bohl and colleagues utilized this same database to assess THA and total knee arthroplasty cases in the first academic quartile, and similarly found no impact of adverse events in cases involving residents. In another study, they found the rate of adverse events among patients who underwent spine surgery during the first quarter was higher in cases involving residents, compared with cases without resident involvement. However, this change was consistent throughout all 4 academic quarters and thus no July effect was found.

Top priority

Practicing surgeons developed their surgical skills and medical decision-making abilities while training as a resident and fellow. Without this process, there would be no mechanism for training the next generation of orthopedic surgeons. The question of whether the involvement of surgical trainees negatively impacts patient care is a reasonable question for patients to ask.

The data suggest resident involvement in a wide variety of orthopedic surgeries has no significant impact on patient morbidity and mortality. To a large degree, both the surgeons-in-training and their supervising attending surgeons should be commended for the results that suggest patient care and outcomes remain the priority of training programs. The ability and patience to train future orthopedic surgeons while maintaining high standards of patient care speaks to the dedication and skill of academic surgeons responsible for educating the next generation of orthopedic surgeons.

PAGE BREAK

Disclosures: Romeo reports he receives royalties, is on the speaker’s bureau and a consultant for Arthrex; does contracted research for Arthrex and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex, Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed. Frank reports no relevant financial disclosures.