‘GRADED AUTONOMY’

Graat said he believes the findings are a reflection of residents’ skills.

“I do believe that residents are just as capable as experienced surgeons because the resident has been trained to perform this operation by an experienced surgeon,” he said.

Graat said that surgeons only trust unsupervised operations with residents who have clearly demonstrated their competence and who will call for back up if the surgery becomes too complicated.

“We can conclude that in a teaching hospital residents obviously know their limitations and that surgeons also know the limitations of their residents and therefore can determine whether the resident can perform the operation unsupervised,” Graat said.

It’s possible that the results reflect some form of cherry picking - that attending surgeons might have jumped in on the more complicated patients, leaving the simpler cases to residents.

Graat’s team tried to account for the severity of each case, and they found that the number of burst or damaged appendices, which would make a surgery more difficult, were the same for each group of doctors.

Hutter said it’s still difficult to completely account for residents’ potentially getting the easier cases because the patients were not randomly assigned to each physician.

“The attending surgeon probably has a lot of information passed on to them to decide whether to do the surgery or pass it on to a resident,” he said.

But the results show that this system seems to be working in terms of patient safety.

Hutter said giving residents “graded autonomy” - meaning, greater levels of responsibility and independence as they become more skilled - is important for training them.

“The goal is to train safe and effective surgeons…and it appears what they’re doing is safe - having surgeons involved in some cases, not involved in others,” Hutter told Reuters Health.

Hutter said it’s hard to say whether the rate of surgeries performed by residents in this study is similar in other hospitals, because teaching centers vary widely in how much supervision they require.

SOURCE: Annals of Surgery, April 2012

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Appendectomy by Residents Is Safe and Not Associated With a Higher Incidence of Complications: A Retrospective Cohort Study

Graat, Leon J. MD; Bosma, Eelke MD; Roukema, Jan A. MD, PhD; Heisterkamp, Joos MD, PhD